Healers Abroad Americans Responding to the Human Resource Crisis in HIV/AIDS (2005) / Chapter Skim
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2 Confronting HIV/AIDS on the Ground
2 Confronting HIV/AIDS on the Ground
Pages 44-67
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From page 44... ...
Just a few decades ago, these diseases represented the primary unfinished agenda in global health. That situation changed with the emergence of HIV/AIDS, the modern successor to the great pandemics of history.
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, the problem of drug resistance, elements of a comprehensive care model for those infected in developing countries, clinical entry points for treatment and care, and issues in providing ART and HIV/AIDS care in resource-limited settings. HIV/AIDS, TUBERCULOSIS, AND MALARIA Linkages Among the Three Diseases In an attempt to target high-risk individuals, health programs addressing malaria, TB, and HIV infection often focus on biologically vulnerable groups.
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. Indeed, the World Health Organization has identified the world's 1.2 billion people living in absolute poverty as most vulnerable to malaria, TB, and HIV infection (WHO, 2002b)
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. Although not as strong, an association between HIV infection and clinical malaria has also been identified in pregnant women (Ladner et al., 2002, 2003)
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Malaria treatment is also complicated by growing drug resistance in most endemic countries, a situation that has led to an increase in deaths from the disease over 10 to 20 years; nonetheless, failing drugs such as chloroquine remain in widespread use, especially in sub-Saharan Africa (IOM, 2004)
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From page 49... ...
: · Behavior change programs to promote condom use, reduced numbers of partners, mutual monogamy, abstinence, and delayed initiation of sexual activity · Prevention and treatment of sexually transmitted diseases · HIV counseling and testing · Harm reduction programs for injecting drug users · Prevention of mother-to-child transmission · Blood safety practices · Infection control in health care settings · Policy reforms to reduce the vulnerability of women and girls, and to ensure the legality and availability of proven HIV prevention strategies, such as use of condoms and clean syringes · Prevention programs specifically designed for people living with HIV IMPACTS OF HIV/AIDS The social, economic, and political impacts of HIV/AIDS affect all levels of society, from individuals and households to businesses and governments.
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. Prior to the availability of ART, the percentage of hospital beds occupied by HIV patients -- ranging from 30 to 70 percent -- indicated that HIV/AIDS was absorbing much of the existing capacity of health services in highly affected countries.
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has identified numerous opportunistic infections and cancers that, in the presence of HIV infection, constitute an AIDS diagnosis. In 1993, CDC expanded the criteria for an AIDS diagnosis in adults and adolescents to include a CD4 T-cell count at or below 200 cells per microliter in the presence of HIV infection (above the age of 5, persons with normally
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The burden of pediatric HIV infection is directly linked to HIV prevalence among pregnant women, which exceeds 25 percent in some parts of Africa. The risk of mother-to-child transmission also correlates with increasing immunosuppression and maternal viral load.
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As HIV-related immunosuppression progresses, the spectrum of illness seen among the infected in the developing world differs from that seen in HIV-infected residents of western countries. In Africa, for instance, people with early HIV infection are more likely to develop TB, bacterial pneumonia, or septicemia.
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TREATMENT AND CARE Antiretroviral Therapy2 The goal of ART is to inhibit viral replication while minimizing the side effects and toxicities of currently used drugs. The inhibition of HIV replication permits restoration of the immune system.
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In addition to possessing separate mechanisms of action, each class also possesses unique effects and toxicities.3 Triple combinations are the most effective way to treat HIV infection. Highly active antiretroviral therapy (HAART)
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The World Health Organization recommends that countries planning to implement ART programs concurrently introduce sentinel surveillance systems for HIV drug resistance. The presence of a resistant virus in a population also complicates the delivery of ART at the local level because it necessitates diagnostic tests for resistance testing, the expertise to interpret and act upon the test results, and a larger armamentarium of antiretroviral drugs.
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. Comprehensive Health Care for HIV/AIDS in Developing Countries Ideally, a comprehensive approach to treatment and care for people with HIV/AIDS includes a range of components, including the following: · Community and national treatment, care, and prevention guidelines · Education and awareness programs · Programs to address stigma and discrimination · Voluntary counseling and testing with informed consent in health facilities, along with services targeting vulnerable and difficult-to-reach populations · Prevention of mother-to-child transmission · Prevention and treatment of opportunistic and sexually transmitted infections · Antiretroviral therapy and monitoring, including essential laboratory and clinical backup and drug management systems · Embedded operations research programs designed to elucidate the most effective approaches to HIV/AIDS care and delivery in resourcelimited settings · Adherence support · Social protection, nutrition, and welfare and psychosocial services · Palliative and home-based care · Bereavement support In reality, however, different models of comprehensive health care delivery for HIV/AIDS will be needed to respond to the diverse requirements
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From page 58... ...
. One survey of 48 African palliative care services for patients with AIDS found that 94 percent had experienced obstacles, especially a lack of trained providers; stigma; and government restrictions limiting access to narcotics such as oral morphine, which controls pain and diarrhea in the terminal phases of AIDS and allows many patients to stay in their homes without the cost or disruption of transfer to a hospital (Harding et al., 2003)
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. Rapid testing methods that can provide reliable results within minutes and require relatively little laboratory capacity are a practical tool for voluntary counseling and testing outreach settings in developing countries.
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Routine testing of pregnant women (with the right to refuse) is recommended as part of worldwide efforts to expand access to ART and programs to prevent mother-to-child transmission of HIV, in the 2004 joint United Nations and World Health Organization policy statement on HIV testing (UNAIDS Global Reference Group on HIV/AIDS and Human Rights, 2004)
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The approach starts with education and voluntary counseling and testing, followed by the initiation of ART and prevention of opportunistic infections, and culminating in the medical management of advanced HIV/AIDS by progressively tiered health professionals. BOX 2-1 The World Health Organization's Strategy for Comprehensive Chronic Disease Care in the Developing World · Shift the emphasis from acute, episodic care to providing continuity of care with planned visits and regular follow-up.
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2003. Provision of Antiretroviral Therapy in Resource-Limited Set tings: A Review of Experience up to August 2003.
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2004. Global AIDS Program: Strategy on Voluntary Counseling and Testing (VCT)
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2002. HIV infection, malaria, and pregnancy: A prospective cohort study in Kigali, Rwanda.
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2003. Antiretroviral Therapy in Primary Health Care: Experience of the Khayelitsha Programme in South Africa: A Case Study.
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2004. 2004 Report on the Global AIDS Epidemic: 4th Global Report.
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2003a. Emergency Scale-Up of Antiretroviral Therapy in Resource Limited Settings: Technical and Operational Recommendations to Achieve 3 by 5; Report of the WHO/ UNAIDS International Congress Meeting on Technical and Operational Recommenda tions for Emergency Scaling-Up of Antiretroviral Therapy in Resource-Limited Settings.
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