Combining Antiretroviral Programs with National Tuberculosis Programs in Africa May Prevent Antiretroviral ‘Anarchy’
Access to antiretroviral medications in Africa "could be an important component of a strategy to support people living with HIV and AIDS," but without provision in a structured framework, the introduction of such drugs could result in regional "chaos" and "anarchy," Anthony Harries and colleagues of the National Tuberculosis Control Program in Lilongwe, Malawi, write in a Lancet opinion piece. Africa is the "epicenter" of the AIDS pandemic, but "ironically [it] is the region least able to offer any challenge or opposition to the devastation caused by the virus." In addition to the inaccessibility to needed AIDS drugs, the "health infrastructure is incapable of monitoring viral load, immune status, or side effects of the drugs. Drug procurement and distribution systems are weak, and drug interruptions are likely. Theft of drugs from health institutions for sale in markets, shops, private clinics and across national borders is a real concern. There are no monitoring systems in place to check on drug adherence or drug effectiveness." However, the authors write, "We believe that it is feasible to put such a system in place in the public health sector based on the successful model adopted for tuberculosis control ... to initiate a combined tuberculosis and antiretroviral drug program." A system to deliver antiretrovirals would be based on the "successful" directly observed treatment, short course (DOTS) model used to deliver TB medicines. The goals of an antiretroviral program would be to reduce mortality, morbidity and HIV transmission; treat symptomatic HIV patients with "standardized, combination antiretroviral therapy"; and achieve 90% or higher treatment adherence rates for the life of the patient. The authors note that the last goal is the "highest priority," as high adherence rates reduce the risk of the development of drug-resistant HIV strains.
Successful Program Elements
Based on the DOTS program, the authors recommend five "key elements" for an antiretroviral delivery program:
- Government commitment: Nationwide coverage is the goal of the program, with technical leadership stemming from a central antiretroviral unit integrated with the national tuberculosis control program.
- Case detection through passive case finding: The program should focus on moving symptomatic HIV-seropositive patients through voluntary counseling and testing and into therapy. Offering drugs to asymptomatic HIV-positive individuals is not feasible in countries with few resources, and early treatment increases the risk of "cumulative side effects, poor adherence and the development of multidrug resistance."
- Standardized antiretroviral regimens: The drug combinations must be simple and bear the least number of side effects. Protease inhibitors are "best avoided" due to their interactions with tuberculosis medicines. A DOT program for the drug regimens must be "flexible," as there currently is no once-daily treatment for HIV infection.
- Establishment of a regular drug supply: The "regular and uninterrupted procurement, distribution and safe storage of antiretroviral drugs" is needed for the program.
- Establishment and maintenance of a monitoring system: Within each program, an antiretroviral register should be established to record individual patient information, with regular reporting on a quarterly basis.
Harries and colleagues write, "We believe than an integrated tuberculosis and antiretroviral drug program is the best way forward." Such a joint program would be "more cost-effective to build on the infrastructure already on the ground for tuberculosis control," as these programs already have the experience of providing, monitoring, and supervising care over time and can contribute to the effective and safe administration of antiretrovirals. In addition, as HIV is the "main driving force" behind the current TB epidemic in Africa, a joint program could best alleviate the TB "burden" on the continent. And as TB is the "main opportunistic infection" from HIV, many patients will be common to both programs. The writers provide a series of recommendations for a joint initiative:
- Use a central unit responsible for the operational running of all program aspects;
- Regularly monitor for antiretroviral drug resistance;
- Prepare a joint program manual;
- Establish a recording and reporting system;
- Design a plan of supervision;
- Provide a team of counselors for disease counseling and support;
- Establish voluntary HIV counseling and testing;
- Secure a regular supply of antiretroviral drugs;
- Prepare a development plan for program funding.