Kenyan Researchers Propose Model for Integrated Antiretroviral Therapy Approach in Lancet Infectious Diseases
There is currently "no agreement on program infrastructure, a standardized [HIV treatment] regimen, drug procurement and distribution and no agreed-upon monitoring levels" in Kenya, making it difficult for a "common strategy and coordinated approach" against HIV/AIDS to be mounted, Miriam Taegtmeyer of the Liverpool School of Tropical Medicine and Kenneth Chebet, director of the AIDS Control Program in Kenya, write in the "Personal View" column of the January issue of the Lancet Infectious Diseases. Representatives from the Ministry of Health, National AIDS Control Council, the donor community, non-governmental organizations and the private sector recently convened in Nairobi to discuss the "realities" of administering antiretroviral therapy to Kenyans. Only about 2,000 of 2.2 million HIV-positive Kenyans currently receive antiretroviral therapy, primarily through a network of private physicians and donor projects. According to the authors, each project varies in scope and has selected its own drug regimen, training module and monitoring system. "Despite good intentions, the result [of the patchy network] may well be ... 'antiretroviral anarchy,'" they state, adding that the lack of comprehensive guidelines could lead to poor treatment adherence and the rise of drug-resistant HIV strains. At the Nairobi meeting, it was "clear that the private sector and the academic establishment in Kenya (who mostly double up as private practitioners) aim to maintain the highest standard" of care utilizing a physician-based treatment and monitoring approach, Taegtmeyer and Chebet write. However, Kenya has limited resources, with nutritional and other public health problems taking precedence, they state, adding that although the donor and political climate appear "committed to attempting a limited public sector approach" to antiretroviral treatment, "significant challenges" remain.
A Plan to Introduce Limited Treatment
Taegtmeyer and Chebet propose a three-pronged plan for a more integrated introduction of antiretroviral therapy in Kenya. The first step is to choose a program design and a standard treatment regimen. The choice of program design depends upon "capacity as much as commitment" and will impact drug distribution, treatment monitoring and supervision of the program as a whole, they write. They recommend following WHO guidelines for first-line treatment by introducing two nucleoside reverse transcriptase inhibitors and one non-nucleoside reverse transcriptase inhibitor and then using a "standard salvage regimen" for patients who do not respond. After a program and treatment regimen have been agreed upon, officials must create a standard training program that covers dispensation and monitoring of the drugs and their side effects, Taegtmeyer and Chebet write. The government then must set up a licensing and accreditation agency for health personnel working with HIV/AIDS patients and centers distributing AIDS drugs. The health department has already established a standards and regulatory service that could be the "ideal forum for legal accreditation and licensing of limited outlets" for dispensing the drugs, they note. "If there is the will to do so and a strong leadership role is taken by governments such as Kenya, then it is possible to overcome challenges and start to introduce antiretrovirals safely and effectively in parts of the world where they are most needed," the authors state. However, "[f]or any such program to work it needs to pull together the private and public sectors under a common umbrella and to harness the inputs of NGOs, multinationals and donor agencies," they conclude (Taegtmeyer/Chebet, Lancet Infectious Diseases, January 2002).