THE CCISD’s POSITION ON ANTIRETROVIRAL TREATMENT (ART) IN RESOURCE-POOR SETTINGS

 The present stance applies to circumstances in which the CCISD is invited to participate in the use and promotion of antiretroviral treatment (ART) in countries where seroprevalence is higher than 1% and the GNP less than $1000 US per capita (i.e. The African continent—from the Sahara down—and Haiti).  In these settings, HIV/AIDS is a public health concern requiring strong yet prudent management.  Recent ART availability, now made more affordable as a result of concerted efforts aimed at expediting their accessibility to developing countries, would need to be re-examined in a public health perspective, going beyond the simple humanitarian concern of individual patient care and treatment.   

Over more than 10 years, the CCISD has attained international recognition in the field of STI/HIV/AIDS prevention—most particularly in developing countries, where heterosexual transmission is predominant.  Prevention strategies have proven both feasible and efficient.  It is imperative that they be maintained.  Regrettably, pressure has been building for a more massive use of ARTs, thus shifting the emphasis, from prevention, toward individual patient care and treatment.  In this context, we have felt the need to take a clear institutional stance, based on the prevention-care continuum.  

In November 2001, the CCISD participated in a meeting convening representatives from the major Canadian projects involved in the fight against AIDS in resource-deficient countries.  The resulting consensus paper[1], formalized soon after by the Canadian Public Health Association (CPHA), has served as the basis for the present text.  This document does not reject the introduction of ART, but rather recommends its rational and efficient use, based on public health care principles and in the perspective of sustainable development.  

Some concepts need to be considered prior to the widespread introduction of ARTs in resource-deficient countries, namely:  

•  That ARTs are  
   

  • suppressive rather than curative drugs; meaning that, in order to avoid developing a resistance to the virus and/or prevent a drop in drug efficacy, patients would need to take them, in accordance to constraining schedules, for the rest of their natural life. Guaranteeing longer-term availability of these drugs would therefore be paramount.
     

  •  very powerful drugs with major side-effects that must be monitored and corrected to avoid serious prejudice to the patient. This brings to bear the entire infrastructure and staffing issue: the quality and availability of both would need to be ensured—and certainly not by way of budget cuts imposed on an already deficient health care system.
     

• That research has demonstrated a growing resistance of HIV to ART.  Regrettably, the development of new molecules has also proven a long and costly process—too slow to catch up with its target’s progression.  And if virus resistance is not considered as an argument against ART, every measure should, at the very least, be taken to delay or to minimise its occurrence, including:
   

  • strict management of supply and distribution (which is rarely the case in African countries)
     

  • the absolute compliance of patients
     

  • tight clinical and biological control of ART drugs, as well as the development of facilities capable of monitoring the emergence of resistance (therefore needing to rely on sophisticated technology).
     

• That the HIV screening of patients is a prerequisite.  Unfortunately, in Africa, in the majority of instances where this was attempted, it prompted stigmatization and violence toward those who had been officially declared “HIV positive” (most notably toward pregnant women, anxious to prevent mother to child transmission).
   

• That, even if the infrastructures, the drugs, and the human resources were available, it would be unrealistic to think that we could treat everyone infected.  Unfortunately, selection criteria for ART candidates raises ethical dilemmas: though steering away from current practises prioritizing the elite, and socially and politically pre-eminent individuals, how can it become socially and politically acceptable to prioritize the treatment of commercial sex workers—a group we know to be greatly affected and which is playing a major role in HIV transmission—, who are often foreigners practicing a shunned profession?
   

• That, in order to oversee the feasibility of such a strategy and establish its priorities, realistic estimates of financial and social costs will have to undertaken—estimates which would not only need to cover investments (both in human and financial resources), but recurrent costs as well, as each individual country would ultimately hold the responsibility of the project’s sustainability.

 The CCISD’s Position

Before contributing to a given ART distribution program request in a resource-deficient country, the CCISD would need to verify that the request takes the following into account:

•  involved health care services’ abilities in meeting the minimum criteria necessary to ensure the rational use of ART.  Measuring tools—such as the one developed by John Snow Inc.’s International Division[2]—can provide preliminary evaluation of field conditions (strengths/weaknesses) and suggest corrective interventions to be integrated to the given project, as needed;
   

• the security and the stable supply of drugs;
   

•  major prevention programs already be in place (synergy);
   

•  the need to improve more equitable access to health care;
   

•  the need to strengthen the basic health care system by securing:
   

  • a comprehensive and universal access to confidential screening and counselling services;
     

  • an uninterrupted supply of drugs;
     

  •  proper clinical monitoring, and the treatment of complications;
     

  • proper clinical and laboratory services able to monitor the ART and its potential side-effects;
     

  • an efficient pan-national control of STIs and tuberculosis.

Finally, regarding medicinal prevention of mother to child transmission: because low-cost interventions can spur major developments in maternal health services, infection control, or rape crisis support, the promotion of medicinal prevention (e.g. nevirapine) is recommended—provided the drugs be kept safe from forceful conversions, and that every precaution be taken to prevent resistance to treatment stemming from improper use. Intended programs would need to prove they support the overall improvement of maternal health services.