Delivering a Lifeline: Comprehensive Antiretroviral Therapy Programs
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ART outreach at the Mahatma Gandhi Clinic.
Source: FHI/Zambia |
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As part of its broad effort to fight the global pandemic of
HIV/AIDS, the U.S. Agency for International Development (USAID)
makes large and important contributions to providing antiretroviral
(ARV) drugs in developing countries, where HIV infection results in
far too many deaths.
Individuals living with HIV do not succumb to the virus itself.
Rather, the HIV virus weakens the body’s immune system to a
point where it is unable to defend itself against illnesses that
healthy immune systems are usually able to stave off. Ultimately, it
is these other illnesses that cause death. As such, antiretroviral
drugs have been a lifesaving advance in the treatment of HIV/AIDS
because they limit the virus’ power to weaken the immune system.
Evidence shows that programs providing ARVs in resource-limited
settings can be remarkably successful, with treatment adherence and
clinical outcomes comparable to those in developed countries. In its
work in the developing world, USAID recognizes that, in addition to
the necessity of ARVs being available and accessible, it is equally important
to help host countries provide critical support to ensure
drug therapy occurs – and on terms that will make it effective. For
this reason, USAID not only focuses narrowly on the provision of
ARVs themselves but also works broadly to establish a full system
for the achievement of antiretroviral therapy (ART), a term that denotes
a comprehensive program of treatment, care, and support.
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Antiretroviral drugs are just one aspect of a comprehensive
HIV/AIDS treatment, care, and support program that includes
meeting the medical, psychological, socioeconomic,
and legal needs of those affected by the disease. In USAID’s
ART programs, the treatment component consists of the
use of at least three ARV medications. The objective of the
drug component is to suppress HIV replication and slow
the progression of HIV disease. |
Antiretroviral Therapy:
Benefiting Individuals and Communities
When antiretroviral drugs are delivered through a broad ART effort,
they provide important benefits for both individuals and communities.
For example, they can dramatically decrease the number
and severity of illnesses associated with HIV infection. They can
prolong the life and reduce the suffering of HIV-positive people.
Enabling patients to live longer maintains the integrity of families,
societies, and economies, particularly in severely affected countries.
When HIV-positive people receive ART, they are able to maintain
not only their health but also their productivity. They are able to
find and keep jobs and to continue to earn an income, provide for
their children, and pass on their knowledge to future generations.
Pregnant and breastfeeding mothers who are receiving treatment
can reduce the risk of passing the virus to their babies. Treatment
allows for a more effective, productive workforce, as AIDS patients
can continue to work. ¹ ²
Properly implemented ART programs also allow for more effective
prevention by reducing the stigma associated with HIV and reducing
HIV transmission. Reducing transmission and the number of
new cases makes providing treatment more affordable. Because
ARV treatment is effective, it has been shown to reduce stigma associated
with HIV testing. People are less afraid to be tested and
find out their HIV status, since they know they have options if they
are positive. Treatment can reduce the stigma associated with HIV,
since it enables people to return to a better health status, and others
in the community realize that HIV-positive people can continue
to live and lead fulfilling lives.
The resources USAID provides for treatment can help improve infrastructure
for prevention and other health services. The training
USAID provides to health providers and the improvements it
brings to laboratory services, pharmacy, logistics, commodity management,
and health information systems can benefit both treatment and prevention services. Furthermore, in many countries, a
large number of health care workers are themselves infected.
Treatment enables these health professionals to continue to provide
critically needed AIDS prevention and treatment services, as
well as other health care services to the community.
| Delivering Antiretrovirals Swiftly, Safely, and Effectively: SCMS Project Marks Third Year |
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| Essential HIV/AIDS medicines and supplies flow through this SCMS warehouse. Photo courtesy of PHD. |
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October 2008 marked the third year of the PEPFAR Supply
Chain Management System (SCMS) project, administered
by USAID. SCMS has had continued success in establishing
secure, reliable, and sustainable systems for procuring quality
pharmaceuticals and other products for care and treatment
of persons living with and affected by HIV/AIDS. In fact,
since the beginning of the project, SCMS has delivered just
over $200 million in HIV/AIDS commodities. In fiscal year
2008, SCMS purchased pharmaceuticals in 25 countries,
managing more than $140 million worth of procurement
worldwide. This effort made it possible for roughly 850,000
patients to receive antiretroviral (ARV) medications.
Consistently, more than 90 percent of ARVs purchased
through SCMS are generics, amounting to savings of
approximately $200 million from the cost of equivalent
branded drugs – savings that can be used to fund treatment
for even more patients. |
Providing Quality Medicines for People Living With and Affected by HIV/AIDS
As a partner in the U.S. President’s Emergency Plan for AIDS Relief
(Emergency Plan/PEPFAR), USAID plays a key role in U.S. Government
efforts to introduce antiretroviral therapy in countries
throughout the developing world. The service delivery systems introduced
through PEPFAR will be sustained with increasing support
from host-country government budgets and staffed with
well-trained personnel who can continue the training process.
USAID also supports targeted research, development, and dissemination
of new technologies, as well as packaging and distribution
mechanisms for antiretroviral drugs.
In fiscal year 2005, for instance, PEPFAR established the Supply
Chain Management System (SCMS) project, which is helping host
nations increase their capacity for delivering essential lifesaving
HIV/AIDS medicines and supplies to people in need of treatment
and care. Operating in some of the countries most severely impacted
by HIV/AIDS, SCMS works in collaboration with host-country
governments and local and global partners; procures essential
medicines and supplies at affordable prices; helps strengthen and
build reliable, secure, and sustainable supply chain systems; and fosters
coordination of key stakeholders.
Administered by USAID, the SCMS technical approach centers on:
- Working with and strengthening existing systems, not creating
parallel or duplicate systems
- Building local capacity, empowering in-country partners to enhance
and develop sustainable and appropriate responses for
their own communities
- Delivering quality HIV/AIDS medicines and supplies at the
best value by leveraging industry best practices for planning,
procurement, storage, and distribution
- Promoting transparency to ensure that accurate and timely
supply chain information is collected, shared, and used to improve
decisionmaking
- Collaborating with in-country and international partners to
identify needs, fill gaps, avoid duplication, and share best practices
SCMS offers partners a rapid, regular, and reliable supply by storing
forecasted quantities of the most frequently requested essential
medicines, HIV test kits, and other products close to the point of
use at regional distribution centers (RDCs) in Ghana, Kenya, and
South Africa. The RDCs follow commercial best practices to ensure
security and quality of the products as well as timely delivery.
By working closely with partners to plan future procurement, pooling
orders to buy in bulk, establishing long-term contracts with
manufacturers, and purchasing generic alternatives whenever possible,
SCMS helps to reduce the price of essential medicines to treat HIV/AIDS.
Six Critical Components of USAID's HIV/AIDS Antiretroviral Therapy Programs
There are many complex issues related to delivering ARVs in resource-constrained settings. USAID has been a leader in developing responses
to these issues, providing support directly to patients and health workers, as well as building the capacity of national health systems.
| Infrastructure for ART Services: Improving infrastructure,
including laboratory capacity, health facilities,
and procurement and distribution of ARVs and
other treatment-related commodities, is critical to
quality provision of services. Many countries do
not have the resources for building facilities or creating
space within existing structures for providing
ART programs. They also lack laboratory equipment
and supplies to provide quality assurance or
conduct training. USAID supports health system
facility infrastructure, including building or repairing
facilities and electrical systems, installing communications
and information systems for record keeping,
and supporting facility supervision and
management. USAID also improves and updates
laboratories, providing quality improvement and
information systems. |
Innovative Models for Quality ART: USAID-supported ART programs use “network”
models of ART service delivery. These models reflect country-specific
strategies to deliver ART services and seek to allocate personnel who are highly
specialized in HIV to work in central hospitals and general health workers trained
in ART to administer treatment at clinics and primary care facilities. Programs are
also designed around the local context and circumstances, including the political,
social, cultural, economic, and epidemiological context (such as the prevalence of
HIV). The level of personnel and physical infrastructure available to deliver ART
varies among countries and affects service delivery – some countries have more
facilities and health professionals to provide ART, while others have far fewer of
these resources. USAID works with local health systems to determine appropriate
and acceptable models for ART services and supports operations research to
ascertain and demonstrate that models are safe, effective, and sustainable. |
| Support for National Policies and Monitoring and
Evaluation Systems: USAID supports the development
and improvement of national-level ART delivery
policies and guidelines. This includes working
with manufacturers and the U.S. Department of
Health and Human Services’ Food and Drug Administration
to facilitate a fast-track approval
process to review and approve appropriate high-quality
ARVs. USAID also supports the development
of laws and policies that ensure a quality
program for procurement, delivery, and administration
of ARVs. In order to guide the planning and
management of national programs, USAID provides
comprehensive monitoring and evaluation of
ART activities and supports the development and
implementation of information systems for both
facility-level ART programs and community-based
programs. The data provided from these systems
allow USAID’s partners to examine key indicators,
such as retention rates from ART clinics, and allow
for continuous program improvement. |
Strengthened Logistics Systems to Ensure ARV Availability: Providing support for treatment
programs requires a serious commitment to supply chain management.
Weak supply chain infrastructure, difficult environmental conditions, and a lack of
human capacity to ensure that essential products reach ART points of service are
considerable hurdles. Medications must be stored and transported in climate-controlled
containers to ensure they arrive in usable condition. USAID programs
strengthen the procurement, supply, storage, and distribution systems for drugs. |
| Support for Patient Adherence: A large component of USAID support for ART is
ensuring that patients adhere to therapy. Adherence to ARVs is crucial to a patient’s
treatment success because nonadherence – even taking less than 95 percent
of the medication – puts patients at risk of viral resistance to their current
regimens. A resistant virus lowers the efficacy of the therapy. Interruptions in
adherence contribute not only to treatment failure in individuals but also to
widespread therapy resistance. Once individuals are determined through clinical
evaluation to be eligible for ART, they enter treatment readiness programs.
These programs educate patients on the importance of adherence, how to deal
with side effects of ARVs, and how to maintain good nutrition to ensure medications
work properly. Adherence to ARVs is often challenging because the side
effects, including headaches, nausea, and skin rashes, can be severe. Once they
begin therapy, patients enter adherence support programs in which health workers,
close friends, or family members also educated on ART conduct follow-up
visits to see if the patient is taking his or her medication correctly, maintaining a
balanced diet, and avoiding opportunistic infections. These adherence support
workers are a critical part of maintaining the effectiveness of ART programs. |
| Capacity Building for Sustainability: USAID recognizes that expanding the provision of ART while maintaining high-quality services requires
ensuring a supply of skilled health professionals. However, trained health workers are in short supply throughout the developing
world, particularly in countries with a high prevalence of HIV/AIDS. The high demand for services coupled with limited human
resources creates an incredible strain on health professionals. USAID helps countries overcome the challenges in expanding ART
provision by improving the training, mentoring, and morale of health care providers at all levels of the health system. Quality training
of health care workers in all aspects of ART is a critical factor contributing to patient adherence. The partnership developed between
patients and health facilities and facility outreach workers can help improve patient retention. |
Components of Quality Antiretroviral Therapy Programs
To assist in reaching the new PEPFAR goal of providing 3 million
people with ART, USAID focuses on activities that directly or indirectly
support the provision of antiretroviral therapy. Antiretroviral
drugs themselves may be less than half of the total cost of treatment,
and ARVs are just one aspect of USAID’s comprehensive
ART programs, which have many other components. These components include: increasing access to ARVs and other medications,
improving the physical infrastructure of laboratories and facilities,
ensuring a consistent supply of quality drugs and commodities,
building personnel capacity to manage ART programs and nutritional
and psychosocial counseling of patients before and throughout
treatment. The opposite page explains in-depth the critical
components of USAID’s ART programs. This brief describes these
essential elements of effective ART programs, with special attention
to the challenges of human resources, infrastructure capacity building,
and support for patients during treatment, and looks more
closely at USAID-supported programs in Zambia, Nigeria, and
South Africa that are meeting these challenges.
Zambia Frontline Perspective:
A Detailed Look at How USAID Supports an Innovative ART Adherence Program
HIV/AIDS is a major threat to Zambians, with an estimated 1.2 million
people infected nationwide. In Zambia, the government has
implemented a policy of providing free ART in order to reduce the
impact of HIV and help sustain the livelihoods of thousands of
households. Increased access to ART is helping reduce death rates
from HIV/AIDS, but the lack of qualified staff to ensure that treatment
regimens are carefully followed is a serious obstacle. Attrition
of health workers is also high in Zambia. While the World
Health Organization and Zambian Ministry of Health (MOH) recommend
staff-to-population ratios of 1:5,000 and 1:700 for doctors
and nurses, respectively, in Zambia these ratios are 1:17,589
and 1:8,064. With more than 250,000 people eligible for treatment,
there is a great need for increasing human resources and improving
infrastructure.
The USAID-supported Zambia Prevention, Care and Treatment Partnership (ZPCT) program strengthens delivery of ART services
by improving the capacity of individuals to provide services; providing
crucial renovations to laboratories, facilities, and equipment;
providing travel reimbursement to workers; and delivering medical
equipment and supplies. These activities boost the morale of overstretched
workers and provide laboratories and pharmacies the
renovations needed to provide quality services. USAID’s ZPCT
program also supports ART outreach services to rural health centers
and strengthens referral networks for lab samples. Between
October 2004 and September 2008, ART services increased from 10 sites serving 1,670 clients to 96 sites serving 62,128 clients.
With a shortage of health workers, the ZPCT also has developed
an innovative strategy of training community volunteers to provide
adherence support and strengthen adherence counseling at the
health facility and community levels. New research carried out by
Family Health International and the MOH has shown the ZPCT’s
strategy to be an effective, low-cost way to achieve high-quality results that may help bridge the human resources gap. This strategy
enables the health system to continue to provide quality ART
to a larger number of patients while easing the workload for facility-based health workers.
The research measured the effectiveness of shifting adherence counseling tasks from health care workers to community volunteers,
called adherence support workers, or ASWs, at five selected
ART sites. The ASWs, who worked alongside doctors and nurses
and were supervised by a professional health care worker, conducted
community visits to track down patients who had missed
their clinic appointments and provided patients with educational
and psychosocial support, referrals, and other encouragement to
improve adherence. The research findings suggested that using adherence
support workers helped reduce waiting times and reduced
loss-to-follow-up (that is, patients who no longer come for
services, no longer take the prescribed treatment, and cannot be
contacted by the program) from 15 percent to 0 percent. The authors
suggested that the ASWs, who are mostly HIV positive
themselves, were in a better position than health care workers to
provide empathetic and emotional support, as well as needed
community follow-up.
Seeing Results: Other Examples of USAID ART Programs
Nigeria: USAID is implementing the largest comprehensive HIV/AIDS prevention, care, and treatment project ever implemented
in a single developing country. The Global HIV/AIDS Initiative
Nigeria (GHAIN) program, funded by the Emergency Plan, is
rapidly strengthening and expanding a wide range of HIV/AIDS
services, including ART. GHAIN works closely with facilities to determine
their capacity and infrastructure needs and improve ART
service delivery. As of August 2008, the program has supported 98
comprehensive ART sites, with more than 54,000 people receiving
ART, and has trained more than 2,500 individuals in ART management,
including pediatric ART.
South Africa: In South Africa, which has the largest number of
HIV-positive people in the world, the epidemic has placed an
enormous strain on the health system and on communities. In
2004, USAID brokered a partnership to provide technical assistance
to local nongovernmental organizations that carry out capacity-building activities with public facilities and other treatment sites
to train health care providers in administering ARVs and full treatment
services. This partnership has created a sustainable means
for providing services, and now the majority of implementing
partners are South African organizations. Treatment has expanded
from 15 sites serving more than 30,000 HIV-positive patients in
2004 to 1,500 sites serving more than 305,000 patients by
March 2008.
Download the PDF version of this issue brief [PDF, 1.4 MB]
1 Ojha V. and Pradhan B. The Macro-Economic and Sectoral Impact of HIV and AIDS in India, 2006. A CGE Analysis. United Nations Development Program (2006).
2 Belle, C., Devarajan, S., Gersbach, H. (2002). Long Run Economic Costs of AIDS: Theory and an Application to South Africa. World Bank; UNAIDS (2002).
The U.S. Agency for International Development works in partnership with the U.S. President's Emergency Plan for AIDS Relief.
November 2008
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