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Call for improved understanding of optimal treatment strategies and greater involvement

HIV experts underscore natural alliance between the response to AIDS and efforts to expand primary care, strengthen health systems in poor countries

Star Health Desk
Speakers at the XVII International AIDS Conference (AIDS 2008) underscored the importance of simultaneously scaling up AIDS programmes and strengthening health systems in poor countries, emphasising that the two goals should be viewed as allies, not adversaries — says a press release by the IntemationalAIDS Society (IAS).
Experts warned that the global shortage of health care workers hampers both goals and demands a collective response. They also stressed the importance of expanding the role of people living with HIV in the planning and provision of health care as a part of the solution.
“HIV and global health advocates have enough common enemies, chief among them political complacency and inadequate human and financial resources,” said Dr. Luis Soto Ramirez, Local Co-Chair of AIDS 2008 and Head of the Molecular Virology Unit at the Institute National de Ciencias M^dicas y Nutricidn Salvador Zubiran and Coordinator of the Clinical Care Committee of CONASIDA, Mexico’s National AIDS Council. "In the struggle to recognise health care as a human right, we are natural partners.” “If the urgency of AIDS and the sheer magnitude of human loss we are now experiencing is not enough to compel us to provide even the most basic level of health care to those living in low-income countries, then we, as a global community, are morally bankrupt,” said Dr. Pedro Cahn, International Co-Chair of AIDS 2008 and President of the International AIDS Society and Fundacidn HuiSsped in Buenos Aires, Argentina. "If, in the context of AIDS, we walk away from this challenge, we may never get another chance.” More evidence to weigh in determining when and how to start treatment
According to Anton Pozniak (United Kingdom) of the Chelsea and Westminster Hospital, the questions of “when to start?” and "what to start with?" remain central to people living with HIV and their clinicians as they consider antiretroviral therapy. The move to start treatment earlier is gaining momentum in light of evidence that those untreated patients with CD4 counts above 350 have significantly higher rates of non-AIDS related illnesses such as cardiovascular disease. Pozniak stated that clinical trials are needed to weigh the benefits of starting earlier with the downsides of earlier therapy, including toxicity, resistance and maintaininglong-term adherence.
Debates regarding which therapies to use in initiating treatment also continue in those coun-
tries where there is an abundance of choice. The first randomised clinical trial to compare the use of boosted protease inhibitors (PI) with non-nucleoside reverse transcriptase inhibitors (NNRTI), both as the anchor of initial treatment regimens, found virological or immunological benefits to both approaches. Pozniak reviewed data on monotherapy with boosted Pls, which may save money and spare users the longterm toxicity of nucleoside reverse transcriptase inhibitors (NRTIs). He also noted some unexpected toxicities associated with regimens using NRTIs as the backbone of treatment. Some nucleosides are used extensively in resource-poor countries despite these toxicities, because of lower costs. Pozniak also presented evidence of the effectiveness of tailored combinations for treatment-experienced patients. He concluded that in situations where there is a choice of therapies, treatment of HIV has become focused on minimising toxicities and maximising convenience, and that this choice should be offered to all people living with HIV.
Strengthening health systems through greater involvement ofPLHIV
According to Morolake Odetoyinbo (Nigeria), CEO of Positive Action for Treatment Access, the greater involvement of people living with HIV (PLHIV) can be a key component of efforts, to strengthen fragile health systems in low- and middle-income countries. These already fragile systems have been further taxed by the HIV epidemic, which has depleted the health workforce due to illness and death, and magnified the impact of existing malnutrition. Odetoyinbo also warned that lack of treatment literacy and unstable drug supplies are leading to HFV drug resistance and multidrug resis tantTB.
Highlighting the existing involvement of PLHIV as counselors, peer educators, and spokespersons, Odetoyinbo explained how PLHIV can do even more to help strengthen health systems if their involvement is rooted in their existing capacities and skills, and not used to simply fill quotas. According to Odetoyinbo, there also must be an environment that allows professionals living with HIV to be actively involved in health systems. PLHIV should have multi-dimensional roles as advocates, watchdogs and managers, and should also be active participants in decision-making bodies responsible for the planning, implementation, monitof-ing and evaluation of programmes.