Global Health Watch 1 in one file

Box B1.6 The pitfalls of expanding anti-retroviral treatment
in developing countries
On the back of inspiring civil society campaigns to reduce the price of
anti-retroviral treatment (ART), millions of dollars are now being directed
at expanding access to these medicines. However, there are several pitfalls
in this largesse that are particularly relevant to countries with underresourced,
disorganized and inequitable health care systems (McCoy et al
2005).
One is that access to ART could be expanded at the expense of other
vital health care services, or could divert resources away from the prevention
of HIV transmission. A focus on ART could also ‘over-medicalize’ the
response to HIV/AIDS, and turn attention away from the political, social
and economic determinants of the epidemic.
A second pitfall is that ART programmes may take inappropriate ‘shortcuts’
to achieve ambitious coverage targets and compromise on the quality
and long-term outcome of care. Insufficient community and patient preparation,
erratic and unsustainable drug supplies, and inadequate training
and support of health care providers could result in low levels of treatment
adherence, tending to an increased threat of drug resistance.
A third pitfall arising out of the pressure to achieve quick results is the
use of non-government supply and delivery systems for ART because of
their ability to set projects up quickly. Apart from the additional burden
of coordinating and monitoring multiple non-government treatment services,
this approach can weaken the capacity of the public sector health
care system still further by draining skilled personnel into the better-paid
independent sector.
Finally, ambitious ART coverage targets may lead to a preferential targeting
of easier-to-reach, higher-income groups, typically those living in urban
areas, and thereby widening existing health care inequities. A treatment–
focused approach that inadequately addresses the basic needs of households,
such as food security and access to water, will limit the capacity of
the poor to benefit from ART.
Narrow, ‘selective’ or disease-based programmes or initiatives are not inherently
bad, nor are they always influenced by undue commercial considerations.
For some health interventions, for example those related to the control
Approaches to health care
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