Differential Access to Antiretroviral Drugs in the Third World: PEPFAR as a Mitigating Agent

The Acquired Immune Deficiency Syndrome (AIDS) caused by HIV is a scourge that is ravaging humanity. A 2005 global epidemic update by UNAIDS puts the total number of people living with HIV at 40.3 million (adults: 38 million; women: 17.5 million; children under 15 years: 2.3 million). The total number of deaths due to AIDS in 2005 was 3.1 million people (children under 15 years: 570,000). There are about 13 million AIDS orphans worldwide-over 90% of these orphans are in Africa. The number of AIDS orphans is projected to reach 25 million in 2010.
Most of the people living with HIV/AIDS live in the developing world.
Access to antiretroviral drugs and HIV care as a whole has been very difficult in the third world. Earlier on, we grappled with the problem of inadequate capacity. There was only a limited understanding about the dynamics of the disease. Many health facilities lacked the capacity to carry out even simple diagnostic procedures such as the rapid antibody tests. And when eventually this capacity was acquired, those who were positive were not able to procure the antiretroviral drugs that were just coming to the third world. The costs were prohibitive. At that time, in Nigeria, for instance, it cost the equivalent of four months salary to procure a month’s worth of antiretroviral drugs. Apart from the fact that many died from AIDS since they could not afford these drugs, it was difficult to carry out quality assurance on these drugs. Those bent on surviving the scourge got involved in some practices such as monotherapy, skipping doses, sharing medications with relatives and so on, laying a good foundation for multidrug resistance.
The third world is a complex place which has defied conventional economic theories. Poverty and disease exist alongside so much wealth. There is a very deep and wide gulf between the rich and the poor. The rich did not have much trouble procuring their antiretroviral drugs. Ofcourse, the rich also acquire HIV!
The WHO has been instrumental in ensuring universal access to antiretroviral drugs. There was the 3 by 5 campaign and recently again, the urgent call to scale up antiretroviral drug access especially to resource-constrained settings. In response, international donors have taken up the challenge almost in a fevered pitch. And in frenzy, many health facilities have opened up their doors, some stopping short of alluring donors.
PEPFAR (President’s Emergency Plan for AIDS Relief), a US government initiative, has served as a mitigating agent for some time in alleviating differential access to antiretroviral drugs in the third world. I am not about to sing the praises of PEPFAR but I simply submit that this program has achieved quite some. PEPFAR serves the center where I work. VCT (voluntary counseling and testing), laboratory investigations, antiretroviral drugs, contact tracing and home-based care, capacity building in terms of health personnel training, facility development and so on are all provided by PEPFAR.
And we have seen results. The patients directly benefit. Their follow-up indices gladden our hearts.
We still have a long way to go. The uptake of antiretroviral drugs in the third world is still unacceptably low considering the burden of the disease.
And it is time governments in the third world (as in Botswana) began to put in place the necessary framework to sustain HIV care when the donors have gone: the donors will not be here forever.

Thank you, Christiane Amanpour

I have just watched Christiane Amanpour’s documentary on AIDS Orphans in Kenya.
The report cannot come at a better time. Though it once again depicts the grim, deathly, hopeless outlook of the African continent, there is a small ray of hope that things can change-this dead horse can live again.
The notion that this kind of report denigrates Africa is utter nonsense. We cannot continue to live in denial. Let all concerned listen to the passionate appeals of Christiane Amanpour, discard the cloak of irresponsibility and act quickly.
See www.cnn.com/eyeonafrica.

Family Medicine in Resource-Poor Settings: The Need for a Paradigm Shift

Family Medicine is that discipline which provides continuing, coordinated, comprehensive healthcare for all patients irrespective of their age, sex, or type of illness. Family Medicine approaches care from a holistic perspective putting into consideration the patient’s family, environment, culture and community and integrating other specialties in a new whole thereby successfully eliminating the reductionist approach to care.
The Family Physician views the family as a unit of care since the concept of family dynamics in health and disease posits that the family influences the causation, perpetuation, therapy, rehabilitation and prevention of disease. Family Medicine takes cognizance of the General Systems Theory which holds that natural entities and phenomena can be organized into specific systems that share common properties. These systems can in turn be allocated into a hierarchy of systems giving rise to the concepts of the suprasystem or biosphere (the community, culture, family) and subsystem (the person/personality, organs, cells, organelles, molecules, atoms and subatomic particles incorporating the genetic makeup). The individual is managed in this context recognizing that an imbalance in either system can lead to ill health.
The well-trained Family Physician has acquired the requisite skills to build on the strength of the family unit since the family is able to harness resources more than the individual in crisis situations.
The Family doctor thus provides primary, family and secondary healthcare, coordinating care when referrals are needed.
I have just described the ideal above. I make bold to say this situation is not what obtains in many resource-limited communities since I am a trainee Family Physician working in such a community. For ages, the West has realized the cost effectiveness and efficiency of using Primary care/Family Physicians in meeting most of the health needs of its citizenry. Current evidence supports this. Though there are instances of inter-specialty wrangling in some Western countries, policymakers/governments still do the right thing by equipping primary care physicians to take care of most ailments in a sustainable way.
Resource-poor countries must quickly shift position and move in this direction even in the face of constraints such as brain drain, poor remuneration of physicians that are still around, prolonged duration of training of Family Physicians, obsolete training facilities, dearth of trainers, inadequate motivation to enter into residency training, excessive workload on those who decide to train, inter-specialty/discipline bickering, among others.
And we must not shift this responsibility to the government alone-all must be involved in creating this system that sustains itself.