To the Editor: As a clinician who delivers antiretroviral therapyin Africa, I have to stress just how far we are from achievingthe goal articulated by former president William J. Clintonin his Sounding Board article on the AIDS pandemic (May 1 issue).1In Kenya, a great deal of medical care is supplied by nonphysicianclinical officers and nurses who lack oversight and have relativelylittle training. There is no requirement or mechanism for continuingmedical education, and brief instructional seminars will notbe sufficient. A model involving the use of unsupervised nonphysicianproviders in rural areas is unlikely to succeed and may insteadlead to the "antiretroviral anarchy" feared by Harries et al.2The alternative of relying on physicians ignores the fact thatmost Kenyan doctors are located in urban areas, where only 16percent of the country's inhabitants live.3
Policymakers should recognize that access to care and high-qualitycare are not the same, and the former does not guarantee thelatter. The provision of dignified care to patients with humanimmunodeficiency virus (HIV) infection in resource-poor settingspresents the most daunting challenge in the history of modernmedicine. Yet this task will prove infinitely more straightforwardthan offering salvage therapy to those with advanced disease.
Jon F. Fielder, M.D. Africa Inland Church Kijabe Hospital Kijabe 00220, Kenya jfielder{at}kijabe.net
References
Clinton WJ. Turning the tide on the AIDS pandemic. N Engl J Med 2003;348:1800-1802. [Free Full Text]
Harries AD, Nyangulu DS, Hargreaves NJ, Kaluwa O, Salaniponi FM. Preventing antiretroviral anarchy in sub-Saharan Africa. Lancet 2001;358:410-414. [CrossRef][ISI][Medline]
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 Clintonand Gayle1 describe the magnitude of the AIDS problem and theresources required to address it. In the context of needingto achieve the maximal value for each dollar spent, an issuethat is not mentioned is the potential diversion of AIDS fundsto education about abstinence and "abstinence-until-marriage"programs. There is little or no valid scientific evidence thatthis form of abstinence education is an effective interventionfor the prevention of AIDS. One anticipates even less chanceof success in an environment where, as Mr. Clinton describesit, conditions are so extreme that trained teachers are dyingfaster than they can be replaced. If the diversion of up toa billion dollars is a political prerequisite for obtainingany funding, then it must be accepted. But before conceding,public health officials within and outside of the current administrationshould be educating Congress (and the public) about more valuableuses for those dollars in AIDS prevention.
Robert K. Gribble, M.D. Marshfield Clinic Marshfield, WI 54449 gribble.robert{at}marshfieldclinic.org
References
Gayle HD. Curbing the global AIDS epidemic. N Engl J Med 2003;348:1802-1805. [Free Full Text]
To the Editor: The history of the HIV–AIDS pandemic inthe developing world — the subject of the articles byClinton, by Gayle, and by Reynolds et al. (May 1 issue)1 —is both inspiring and frustrating. Each achievement in the industrializedworld raises our hope of success. Thanks to the global efforts,multinational pharmaceutical companies have agreed to providehighly active antiretroviral therapy at discounted prices. Nowthere are thousands of people in the developing world who aregetting the benefits of such therapy, which was initially thoughtto be a blessing of the Western world. But substandard HIV diagnostickits are causing much harm in the developing world. Blood transfusionand mother-to-child transmission remain major routes for thespread of HIV and AIDS. We need to motivate the large, multinationalcompanies that make diagnostic tools to provide high-qualitykits for screening and monitoring to developing countries atdiscounted prices. Reliable tests will improve the safety ofblood for transfusions and facilitate prenatal screening andmonitoring of patients receiving highly active antiretroviraltherapy. The use of such therapy without monitoring can encourageirrational medical practices and the development of drug-resistantdisease.
Syed A. Mujeeb, M.B., B.S. Jinnah Post Graduate Medical Centre 74900 Karachi, Pakistan smujeeb{at}cyber.net.pk
Arshad Altaf, M.B., B.S., M.P.H. Aga Khan University 74900 Karachi, Pakistan
References
Reynolds SJ, Bartlett JG, Quinn TC, Beyrer C, Bollinger RC. Antiretroviral therapy where resources are limited. N Engl J Med 2003;348:1806-1809. [Free Full Text]
Dr. Reynolds and colleagues reply: We agree that in areas whereresources are limited, a key requirement for the expansion ofHIV 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, willbe crucial. In-country training programs in the use of HIV diagnostictools and clinical monitoring should be an essential componentof the global effort to treat HIV and AIDS. We support the effortsof a number of recent programs, including the Uganda-based AcademicAlliance for AIDS Care and Prevention in Africa, that includetraining and the transfer of technology in order to facilitatethe sustainable laboratory and clinical infrastructure requiredto fight HIV and AIDS, as well as other infectious diseases.
Steven J. Reynolds, M.D., M.P.H. Thomas C. Quinn, M.D. RobertC. Bollinger, M.D., M.P.H. Johns Hopkins University Baltimore,MD 21205
D'Cruz, O. J., Uckun, F. M.
(2006). Dawn of non-nucleoside inhibitor-based anti-HIV microbicides. J Antimicrob Chemother
57: 411-423
[Abstract][Full Text]
D'Cruz, O. J., Uckun, F. M.
(2005). Discovery of 2,5-dimethoxy-substituted 5-bromopyridyl thiourea (PHI-236) as a potent broad-spectrum anti-human immunodeficiency virus microbicide. Mol Hum Reprod
11: 767-777
[Abstract][Full Text]
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