Care and support for people living with HIV/AIDS

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Care and support for people living with HIV/AIDSwould not be affordable. For example, based on 1997 prices, the provision of triplecombination therapy to all people with HIV in sub-Saharan Africa could consumebetween 9% and 67% of total GDP.As these examples make clear, the ability to secure financing for health care, particularlyfor advanced care options such as antiretroviral therapy, is very limited indeveloping countries. Determining the best buy within the prevailing resource constraints– a recurring challenge for health system decision-makers – must go handin hand with efforts to make health service delivery more efficient and to mobilizeadditional resources for the sector.One of the critical factors for service delivery is the availability of people to deliverservices. As mentioned earlier, AIDS increases the demand on the health sector (seepage 31), and at the same time reduces the human resources available to it by causingillness and death in the sector’s workforce. With fewer health care providersavailable to carry an ever-increasing workload, it is easy to understand why theremaining staff may experience burn-out, which results in a lower quality of serviceand further attrition in the workforce. It is urgent for governments to establish humanresource policies aimed at mitigating these impacts on the health sector (see pages94-96). The desirable response would be to increase the number of health careworkers so as to maintain the sector’s ability to deliver services. This requires decisionsabout the kinds and numbers of health care workers that will be needed, anda clear idea of how the cost of the mitigation efforts will be shouldered.Care and support packagesThe kind of care and support “package” made available to people living with HIV orAIDS will thus depend on the ability to mobilize human, infrastructure and financialresources. Where the ability to mobilize resources is extremely limited (such as inmost of rural sub-Saharan Africa) or somewhat limited (as in northern Thailand), thepackage will necessarily be more limited than where resource availability is relativelyunrestricted.Examples of what the essential, intermediate and advanced packages could compriseare given in the Table 1, page 98.It is important to emphasize that progress in improving health service delivery neednot be strictly linear. For example, planners may discover an opportunity forexpanding access to treatment for multiresistant tuberculosis (an option in theadvanced package) in a region where people with HIV are receiving mainly the intermediatepackage. If so, they should not hesitate to push ahead with this option, inparticular when the prospect for improving delivery of some of the less advancedoptions is poor.In these examples of care and support packages, no consideration is given toimproving health service delivery through greater efficiency and coverage.97
Report on the global HIV/AIDS epidemic – June 2000For instance, possible expansion of community-based care and home care is nottaken into account, nor are considerations of more efficient referral patterns. A furtherlimitation is that they omit health sector activities that are not specific to “care andsupport”.In addition, even when resource constraints are very serious, health services everywhereshould provide care for sexually transmitted infections, family planning services,HIV testing of blood for transfusion, and the promotion of universal precautionsTable 1. Care and support packages, according to resource availabilityThe essentialpackageThe intermediatepackageThe advancedpackage• voluntary HIV counselling and testing• psychosocial support for HIV-positive people and theirfamilies• palliative care and treatment for pneumonia, oral thrush,vaginal candidiasis and pulmonary tuberculosis (DOTS)• prevention of infections with cotrimoxazole prophylaxisfor symptomatic HIV-positive people• official recognition and facilitation of community activitiesthat reduce the impact of HIV infectionAll of the above PLUS one or more of the following:• active case-finding (and treatment) of tuberculosisamong HIV-positive people• preventive therapy for tuberculosis for HIV-positive people• systemic antifungals for systemic fungal infections (suchas cryptococcosis)• treatment of Kaposi sarcoma with essential drugs• surgical treatment of cervical cancer• treatment of extensive herpes with acyclovir• funding for community activities that reduce the impactof HIV infectionAll of the above PLUS:• triple antiretroviral therapy• diagnosis and treatment of opportunistic infections thatare difficult to diagnose and/or expensive to treat, suchas atypical mycobacterial infections, cytomegalovirusinfection, multiresistant tuberculosis, toxoplasmosis,and HIV-associated cancers• specific public services that reduce the economic andsocial impacts of HIV, to supplement community effortsthat reduce the impact of HIV infection98
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Care and support for people living with HIV/AIDS

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