The 2003 revision of the WHO guidelines is intended to support and facilitate the proper management and scale-up of ART by promoting a public health approach that includes the following elements:

  • Scaling up ART, with the objective of universal access.

  • Standardizing and simplifying antiretroviral regimens to support efficient implementation of treatment programs in resource-limited settings.

  • Ensuring a scientific evidence base for ART programs so as to avoid the use of subpar treatment protocols that could compromise the treatment outcomes of individual patients and create the potential for the emergence of widespread drug resistance.

The WHO guidelines emphasize consideration of the challenges to ART programs posed by working in resource-limited settings, including human resources, health system infrastructure, and socioeconomic conditions. The guidelines include recommendations for when to start ART and with which antiretroviral regimens, reasons for changing the treatment, and what regimens to use if such change is necessary. They also address how treatment should be monitored, with specific reference to the side effects of ART, and make recommendations for particular patient subgroups (WHO, 2006a).

PEPFAR recommends that ART include the following elements (OGAC, 2005a):

  • Uninterrupted supply of appropriate ARVs

  • General clinical support for patients, including other medications and diagnostics

  • Training and support for health care providers

  • Infrastructure (clinics, counseling rooms, laboratories, distribution and logistics systems)

  • Monitoring and reporting systems

  • Appropriate referrals

At the same time, PEPFAR officials have recognized that each nation’s needs are unique, and that each nation is therefore in the best position to tailor its plans to fit its particular circumstances. Thus the approach to ART varies considerably among the focus countries. One important factor in this variation is differences in the prevalence of HIV infection; the national HIV prevalence varies more than 20-fold among the 15 focus countries (see Chapter 2). A second salient factor is wide variation in the health care systems already in place. Several countries have well-established medical, nursing, and paramedical education programs, while a few have neither medical nor nursing schools. Access to basic medical services is also highly variable, although most of the focus countries have developed plans for

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