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If the world economic outlook were brighter, AIDS 2010 might be viewed as a turning point in the global HIV response. The conference, which wrapped up last Friday, was the stage for the announcement of the promising potential of the CAPRISA 004 trials on a vaginal microbicide. If the initial results are successfully replicated, the microbicide could offer women partial protection against HIV and herpes simplex II infections down the road. A successful microbicide would be a much-welcomed and desperately needed addition to the arsenal of women-initiated HIV protection, in which the female condom is now alone and greatly underfunded.
Other good news came out of the discussion on antiretroviral therapy (ARVs) as both HIV prevention and treatment and the discussion on the potential for vaccines and other mechanisms to stop HIV transmission by targeting the “mucosal bottleneck,” as described by Dr. Anthony Fauci, head of the United States National Institute of Allergies and Infectious Disease.
But tomorrow’s potential good news was overshadowed by today’s pressing concerns. In Russia, 2,000 people have been forced to stop treatment, and it may be 14,000 people soon if something isn’t done quickly. May other countries are facing a similar situation. Dr. Peter Mugenyi, director of Uganda’s Joint Clinical Research Center, spoke passionately about Ugandans living with HIV who are being turned away from treatment. He warned of “the carnage” of HIV-related deaths if we don’t continue to fund HIV adequately and offer life-saving ARVs.
The World Health Organization has released new guidelines that will require putting more people on treatment. Real questions linger not just about how to pay for it but also about who will do this work in a world where we are desperately short of qualified health workers. This is exactly the question my colleague, Karen Blyth, IntraHealth’s director of HIV/AIDS programs, raised at a session on the human resources requirements for achieving universal access. The term “task-shifting” refers to the delegation of some health care tasks to less specialized health workers when appropriate, and it’s a term that engenders mixed reactions. When done well, task-shifting can offer a viable solution for making health care more available and making more efficient use of existing health workers, especially if task-shifting is supported by health worker training and retention programs. Increasingly, we are seeing solid evidence of the benefits of task-shifting in HIV/AIDS work, notably the Lancet’s recent study on using nurses to monitor patients on ARVs. Task-shifting can offer an innovative way of doing things “faster, better, cheaper,” as former President Bill Clinton urged.
I want to share with you one example I heard about at AIDS 2010 of a type of de facto task-shifting to the patients themselves from a largely unheralded program in Mozambique. This Medecins Sans Frontieres-supported program in Mozambique (see abstract) has succeeded in forming community-based “patient groups,” groups of people living with HIV who monitor each other for adherence to treatment, side effects, and other problems. Every month, one group member goes to the clinic to pick up prescriptions for the entire group. When one member isn’t feeling well, another member will seek a refill on their behalf or see that the person is referred to immediate care if the situation is more serious. Every six months, the entire group goes together to the health facility to be seen by medical professionals. This model reduces the amount of money patients spend on transportation and reduces the amount of time they spend in health facilities as well as the burden on health facilities. Perhaps, just as importantly, these patient groups cultivate a community of support for people living with HIV. It is this kind of innovation that we need to promote if we are going to learn to do more with less while continuing to move towards making universal access to and use of HIV prevention services, counseling and testing, and treatment and care a reality.
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