Care and support for people living with HIV/AIDS

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Care and support for people living with HIV/AIDSHealth care: where are the gaps?Despite decades of effort by communities and governments to improve access tohealth care, and despite the help of WHO and other institutions, the health sectordeficiencies in the developing world appear to be growing instead of shrinking.Even before the epidemic, the health care system did not get a fair share of thenational budget. Typically, health centres and hospitals were short-staffed, facilitiesfor diagnosis were inadequate and drug supplies erratic, and training for health careproviders was uneven and often poor. These deficiencies have worsened with thearrival of the HIV epidemic, which has increased the demands for health care andsimultaneously reduced the health system’s capacity to respond (see page 31).In the poorer developing countries, local health centres and small hospitals lackadequate facilities to diagnose the opportunistic diseases of people with HIV. Theyrepeatedly run out of supplies of essential drugs, including the ones needed to alleviatedistressing symptoms and to manage opportunistic infections. For example,oral thrush – a fungal disease which causes pain on swallowing – could be treatedrelatively easily, but millions of patients continue to suffer for lack of a simple antifungaldrug. Tuberculosis, which can be cured, often goes untreated for the samereason. In Zambia, for example, where the tuberculosis case-load increased sixfoldbetween 1992 and 1998, proper treatment became increasingly problematicbecause health facilities kept running out of TB drugs.Even big teaching hospitals affiliated with urban medical schools – supposedly thebest-supplied part of the health system – have serious problems, to judge from aUNAIDS survey of 22 university teaching hospitals in 19 African and 3 Asian citiescompleted in 1997. The hospitals surveyed had suitable diagnostic facilities and theright drugs to treat three conditions – pneumonia, pulmonary tuberculosis and oralthrush. These are the only HIV-related conditions that are easy to diagnose and inexpensiveto treat. For any other HIV-related illness, diagnostic capacity (X-ray and laboratoryfacilities) and drug supplies were so inadequate that a patient would haveless than a 50% chance of being correctly diagnosed and treated. This was true, forinstance, of Kaposi sarcoma (a frequent HIV-related cancer), serious fungal infectionssuch as cryptococcal meningitis, and viral infections affecting the brain. Relieffor difficulty in breathing was unavailable in half the hospitals. Strong painkillers wereavailable in only two-fifths, despite the fact that most people with advanced HIVinfection require pain control at some point.The high costs of antiretroviral drugs, and the sophisticated medical facilities requiredto track patients’ progress and monitor side-effects, have been major stumblingblocks to access for the vast majority of people with HIV in the developing world.Enormous variations in access to antiretrovirals exist in middle-income countries. Inmost of Asia, people with HIV have limited access. In Thailand, for instance, the89
Report on the global HIV/AIDS epidemic – June 2000Government subsidizes the cost of antiretroviral drugs for patients enrolled in clinicaltrials in a few centres of excellence, but this currently ensures access for onlyaround 2000 of the approximately 70 000 new AIDS cases occurring annually.A few projects in sub-Saharan Africa aim to promote the rational use of treatment forpeople with HIV, including antiretrovirals (see Box 19, page 103). Even within theprojects it has repeatedly been problematic for patients with opportunistic infectionsto have access to the essential drugs they need. Outside these projects, antiretroviralscan only be purchased from a poorly regulated private sector where concernsabout inefficiency and the potential for counterfeit loom large.There are some Latin American and Caribbean countries where even treatment foropportunistic infections is problematic. However, other countries in the region haveresponded to demands from groups of patients, doctors and human rights organizationsand now lead the developing world in providing access to antiretrovirals.Argentina, Brazil, Colombia, Costa Rica and Uruguay provide a legal right to someform of antiretroviral therapy, though the application of the law is somewhat patchy.Coverage of eligible patients has been reported to be 100% in Brazil, 70% inArgentina, 65% in Chile and Uruguay, 40% in Panama and 20% in Ecuador. Somecountries operate with a lottery system or limit antiretroviral drug access to thosewith social security or private health insurance. Experience in Brazil shows that thecosts of such therapy, although high, are offset to some extent by savings on treatmentfor opportunistic infections and on hospital stays (see Box 18, page 101).Nevertheless, some concern has been voiced over the risk that HIV prevention activitiesmay suffer if too much effort and money is devoted to providing treatment.90
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Care and support for people living with HIV/AIDS

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