Comprehensive health care for people infected with HIV in developing countries

Defining services at different levels of health care

The WHO strategy for providing comprehensive care to people with chronic diseases emphasises the importance of defining services delivered at each level of health care, from home care, to community level participation, and to primary, secondary, and tertiary levels of service delivery.3 Delegating roles and responsibilities for specified services to less skilled staff, training primary care providers to deliver some aspects of HIV care, and developing effective communication and referral systems to closely link primary providers to more specialised HIV services could begin to address the need for HIV expertise in resource poor settings. Specially trained HIV providers located at regional health centres or hospitals could provide consultation, management of HIV related conditions, laboratory testing and monitoring, and training for primary care providers.Primary care teams could be trained to carry out clearly defined tasks such as treatment adherence counselling, supporting patient self management, and providing counselling and testing, prevention services, and palliative care in the community.

Coordination of services

Integration and coordination of services are important elements of the WHO chronic disease model that could optimise the use of resources and increase access to HIV care. Counselling and testing services are key components of HIV care and preventing HIV infection,15but the limited services that do exist in developing countries are concentrated in urban areas, whereas most people in Africa and Asia live in rural areas. Thus, most people at risk of HIV infection remain unaware of their HIV status.15

The availability of counselling and testing services could be expanded, particularly for women, by integrating these services into existing vertical programmes such as antenatal care, family planning, and maternal and child health programmes and by linking counselling and testing with HIV prevention programmes. Integrating counselling and testing services with family planning and antenatal care is critical for preventing mother to child transmission. Training HIV prevention workers to perform counselling and testing and making rapid HIV testing technology available will help increase access to such services. In turn, HIV testing should serve as an entry point into HIV care, as in Uganda, where counselling and testing services provide access to antiretroviral treatment and referral to other AIDS services.1

Wider access to HIV care could significantly increase the number of people who seek testing and therefore receive essential prevention counselling.16 HIV care has been successfully linked with HIV prevention programmes in Thailand, Cambodia, Uganda, and Senegal.1 17Brazil is regarded as a leading example of the integration of HIV care and a renewed commitment to prevention.18 Although the provision of government funded antiretroviral drugs has increased access to antiretroviral treatment in Brazil, the extensive HIV treatment and care programme operating in Brazil and other parts of Latin America might be less applicable to countries with a larger proportion of their HIV infected populations living in rural areas with weaker transportation systems.18

Customising models of healthcare delivery

Different models of healthcare delivery will be needed to respond to the diverse requirements for establishing comprehensive HIV care in developing countries. The Pan American Health Organization/WHO, in collaboration with the United Nations Joint Program on HIV/AIDS (UNAIDS) and the International Association of Physicians in AIDS Care, has proposed a phased-in “building blocks” approach to delivering the health services required for comprehensive HIV care,19which shares key elements with the WHO model for chronic disease management. In this approach, the complexity and sophistication of services provided at each level of health care would depend on the availability of technical and financial resources, skilled providers, and healthcare infrastructure in a given setting.

Integration and coordination of services is needed to optimise use of scarce resources for HIV care

The implementation of basic services would provide the foundation for delivering more specialised services. As resources increase, the range and specialisation of services provided at each level of care could increase. For example, a setting may have sufficient resources to train providers to manage counselling and testing and prophylaxis against opportunistic infections at the primary care level, prevention of mother to child transmission and the diagnosis and treatment of opportunistic infections at the secondary level of care, and antiretroviral treatment at the tertiary level. With the availability of more sophisticated tools, training, and supportive infrastructure, the antiretroviral treatment and management of opportunistic infections might prove feasible and effective at more peripheral levels of care, out to the primary care level.

The WHO has also proposed an approach to scale up antiretroviral treatment in developing countries that includes the use of standardised antiretroviral drug regimens.2 This approach could enable primary care providers with basic training in HIV care to provide algorithm guided antiretroviral treatment with the help of evidence based guidelines for monitoring drugs' side effects and toxicities. Providing components of HIV care at the primary health care level would be essential to reach most of those infected, but experiments in healthcare delivery are needed to define what services can be delivered at the primary care level that will improve long term patient outcomes.

Need for research

Health services research is needed to define the most effective and efficient ways for countries to move from their current state of healthcare provision to developing a comprehensive system of HIV care.This research must address questions such as whether and to what extent standardised approaches to antiretroviral treatment and treatment of opportunistic infections decrease HIV related morbidity and mortality, what approaches to providing patient and family support improve adherence to drug regimens, and how best to integrate education and counselling on prevention at patient and community levels.Studies of adherence in resource poor settings have shown that monitoring programmes involving home visits can help patients attain high levels of adherence.20 Designing these services must include the perspectives of people infected with HIV.

Imposing chronic disease management strategies on existing systems of care that are organised to address acute episodic illness is unlikely to be successful. HIV care, like that of other chronic illnesses, requires planned visits and regular follow up. Delivering care for other chronic communicable diseases such as tuberculosis shows the need for close follow up, prevention of antimicrobial resistance, and the effectiveness of directly observed treatment—and such lessons can help guide the care of people with HIV infection and AIDS. A community based model developed in Haiti used existing tuberculosis control infrastructure to deliver antiretroviral treatment to symptomatic patients.21 This programme made effective use of community health workers who provided patient support and education and gives anecdotal evidence of symptomatic improvement among small numbers of patients receiving antiretroviral treatment.21 Research is needed to confirm the impact on various health outcome measures, including survival, of guideline based approaches to antiretroviral treatment in resource poor settings. Ongoing evaluation and monitoring of clinical outcomes is essential.

Need for partnerships

The global epidemic of HIV infection and AIDS continues to spread, and the number of people living with HIV infection continues to increase, with five million new HIV infections and three million deaths from AIDS in 2001. The numbers living with AIDS will probably increase further with effective deployment of HIV care, particularly if prevention efforts are not strengthened concurrently.1Partnerships between donors, governments, non-governmental organisations, and local organisations are essential in developing effective and sustainable prevention and care programmes. Policy statements(such as those made by the United Nations General Assembly Special Session on HIV/AIDS, 2001 22 23), various guidelines,2 19and international training initiatives (including the CDC/HRSA International Training and Education Center on HIV programme, the International AIDS Society training programme, the Academic Alliance for AIDS Care and Prevention in Africa, and the Regional AIDS Training Network in Kenya) must coordinate their training messages and seek compatible, practical models for care delivery. A policy environment in which all sectors of society play a part in addressing the AIDS epidemic is crucial for success. Experience with the WHO care model for chronic diseases may help inform the design of healthcare systems to provide comprehensive care for HIV infection in developing countries, and coordination between these efforts would likely benefit both initiatives.