Correspondence
The AIDS Pandemic
N Engl J Med 2003; 349:814-815August 21, 2003
- Article
To the Editor:
As a clinician who delivers antiretroviral therapy in Africa, I have to stress just how far we are from achieving the goal articulated by former president William J. Clinton in his Sounding Board article on the AIDS pandemic (May 1 issue).1 In Kenya, a great deal of medical care is supplied by nonphysician clinical officers and nurses who lack oversight and have relatively little training. There is no requirement or mechanism for continuing medical education, and brief instructional seminars will not be sufficient. A model involving the use of unsupervised nonphysician providers in rural areas is unlikely to succeed and may instead lead to the “antiretroviral anarchy” feared by Harries et al.2 The alternative of relying on physicians ignores the fact that most Kenyan doctors are located in urban areas, where only 16 percent of the country's inhabitants live.3
Policymakers should recognize that access to care and high-quality care are not the same, and the former does not guarantee the latter. The provision of dignified care to patients with human immunodeficiency virus (HIV) infection in resource-poor settings presents the most daunting challenge in the history of modern medicine. Yet this task will prove infinitely more straightforward than offering salvage therapy to those with advanced disease.
3 ReferencesJon F. Fielder, M.D.
Africa Inland Church Kijabe Hospital, Kijabe 00220, Kenya
jfielder@kijabe.net 1
Clinton WJ . Turning the tide on the AIDS pandemic. N Engl J Med 2003;348:1800-1802
Full Text | Web of Science | Medline2
Harries AD ,Nyangulu DS ,Hargreaves NJ ,Kaluwa O ,Salaniponi FM . Preventing antiretroviral anarchy in sub-Saharan Africa. Lancet 2001;358:410-414
CrossRef | Web of Science | Medline3
Schwarz RA. The health sector in Kenya: health personnel, facilities, education and training. Nairobi, Kenya: Development Solutions for Africa, 1995.
To the Editor:
The excellent Sounding Board articles by Clinton and Gayle1 describe the magnitude of the AIDS problem and the resources required to address it. In the context of needing to achieve the maximal value for each dollar spent, an issue that is not mentioned is the potential diversion of AIDS funds to education about abstinence and “abstinence-until-marriage” programs. There is little or no valid scientific evidence that this form of abstinence education is an effective intervention for the prevention of AIDS. One anticipates even less chance of success in an environment where, as Mr. Clinton describes it, conditions are so extreme that trained teachers are dying faster than they can be replaced. If the diversion of up to a billion dollars is a political prerequisite for obtaining any funding, then it must be accepted. But before conceding, public health officials within and outside of the current administration should be educating Congress (and the public) about more valuable uses for those dollars in AIDS prevention.
1 ReferencesRobert K. Gribble, M.D.
Marshfield Clinic, Marshfield, WI 54449
gribble.robert@marshfieldclinic. org 1
Gayle HD . Curbing the global AIDS epidemic. N Engl J Med 2003;348:1802-1805
Full Text | Web of Science | Medline
To the Editor:
The history of the HIV–AIDS pandemic in the developing world — the subject of the articles by Clinton, by Gayle, and by Reynolds et al. (May 1 issue)1 — is both inspiring and frustrating. Each achievement in the industrialized world raises our hope of success. Thanks to the global efforts, multinational pharmaceutical companies have agreed to provide highly active antiretroviral therapy at discounted prices. Now there are thousands of people in the developing world who are getting the benefits of such therapy, which was initially thought to be a blessing of the Western world. But substandard HIV diagnostic kits are causing much harm in the developing world. Blood transfusion and mother-to-child transmission remain major routes for the spread of HIV and AIDS. We need to motivate the large, multinational companies that make diagnostic tools to provide high-quality kits for screening and monitoring to developing countries at discounted prices. Reliable tests will improve the safety of blood for transfusions and facilitate prenatal screening and monitoring of patients receiving highly active antiretroviral therapy. The use of such therapy without monitoring can encourage irrational medical practices and the development of drug-resistant disease.
1 ReferencesSyed A. Mujeeb, M.B., B.S.
Jinnah Post Graduate Medical Centre, 74900 Karachi, Pakistan
smujeeb@cyber.net. pk Arshad Altaf, M.B., B.S., M.P.H.
Aga Khan University, 74900 Karachi, Pakistan1
Reynolds SJ ,Bartlett JG ,Quinn TC ,Beyrer C ,Bollinger RC . Antiretroviral therapy where resources are limited. N Engl J Med 2003;348:1806-1809
Full Text | Web of Science | Medline
Author/Editor Response
We agree that in areas where resources are limited, a key requirement for the expansion of HIV treatment is the provision of an adequate laboratory infrastructure. The availability of affordable diagnostic and monitoring assays, as well as quality-assurance programs for laboratories, will be crucial. In-country training programs in the use of HIV diagnostic tools and clinical monitoring should be an essential component of the global effort to treat HIV and AIDS. We support the efforts of a number of recent programs, including the Uganda-based Academic Alliance for AIDS Care and Prevention in Africa, that include training and the transfer of technology in order to facilitate the sustainable laboratory and clinical infrastructure required to fight HIV and AIDS, as well as other infectious diseases.
Steven J. Reynolds, M.D., M.P.H.
Thomas C. Quinn, M.D.
Robert C. Bollinger, M.D., M.P.H.
Johns Hopkins University, Baltimore, MD 21205- Citing Articles (2)
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