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HIV Treatment Programs
By Mary Rose

HIV Treatment Programs
Treatment programs have to overcome many obstacles, ranging from patient recruitment to procuring drugs. The following are some of the most significant issues.
HIV counseling and testing is particularly important as a starting point for access to other HIV/AIDS-related services. If a person does not know they are infected, they cannot get any treatment or care. In too many cases people are diagnosed positive when they are already seriously ill. At this point, there are fewer opportunities for cost-effective interventions.
 HIV counseling and testing is important to encourage people to use these services. Raising awareness of the benefits of treatment provides people with an incentive to learn their status, and so should help to increase demand. To help overcome this problem, many countries are moving towards offering every person for test as a routine part of health care, regardless of symptoms.
Patient selection criteria are used to determine who is most likely to benefit from antiretroviral treatment. Usually the patient must demonstrate that they are able to attend the treatment centre regularly and to adhere to daily medication. It may be necessary, for example, to arrange transport to help people meet these requirements. Also, the treatment program may need to help people to find the support they need to cope with the demands of treatment, whether it be from friends, family or support groups. Those who have alcohol or other drug addictions, or depression, need to be helped to overcome their problems before they start treatment.
In the absence of treatment, someone who has is likely to remain healthy for longer if they have an ample and nutritious diet. The need for good nutrition also applies to those who are receiving treatment, especially because some of the drugs should be taken on a full stomach, and little is known about the effects of antiretroviral on malnourished people. One study in Singapore found that malnourished people were less likely than others to benefit from the medication.6 Researchers in Malawi found that severely malnourished patients were six times more likely to die in the first three months of treatment than those with a normal nutritional status.
Furthermore, if someone lacks an adequate food supply then they are less likely to be able to adhere to a daily treatment regimen. Hunger is a much more immediate problem than the threat of AIDS, and desperate people may even resort to selling their drugs to feed themselves and their families.
Antiretroviral drugs can stop working if they are not taken every single day. It is therefore essential to maintain an uninterrupted supply of medication, from the factories where the drugs are made all the way down to the rural villages where they are needed. This presents difficulties because in many countries the distribution systems for all kinds of medicines are chronically weak and unreliable. Transport and communication networks are often in very poor condition.
In September 2005, PEPFAR awarded a contract for supply chain management to a consortium led by John Snow International and Management Sciences for Health. Their system is intended to handle a wide range of HIV/AIDS related products, including drugs and laboratory equipment, for US-funded projects around the world. Several members of the PEPFAR supply chain consortium also participate in the AMDS.
The parts of the world worst affected by AIDS have a dire shortage of health workers. In particular Africa, which is home to 14% of the world’s population, and carries 25% of the global disease burden, has only 1.3% of global health workers. This shortage is one of the most serious problems facing antiretroviral treatment programs.
One reason for the paucity of health workers in poor countries is the international poaching of doctors and nurses by Europe and North America. Skilled professionals are lured abroad by better working conditions and much better pay. This migration satisfies the needs of the rich countries, but drains resources from nations that can ill afford to lose

the workers they have spent so much money training. Rates of health worker migration range from 8% to as high as 60% in some African countries.
AIDS also contributes to the shortage of health workers. In the worst affected countries, doctors and nurses are dying of AIDS at such a fast rate that training colleges struggle to produce enough replacements. Botswana lost approximately 17% of its health-care workforce due to AIDS between 1999 and 2005.
In response, many countries are working hard to expand recruitment and training schemes. Some have also sought to ease the shortage of health workers by recruiting doctors and nurses from abroad, against the usual flow of worker migration. Difficulties can however arise if the foreign workers are unable to speak local languages, or are unused to the local way of life.
An increasingly popular alternative is to move many of the routine tasks of AIDS care from more specialized to less specialized staff. Doctors can ease their workload by transferring duties to non-physician clinicians; clinicians can shift tasks to nurses or midwives; and the less technical jobs can be handed over to counselors or community health workers. With sufficient organization, one treatment specialist can oversee thousands of doctors, who in turn can supervise tens of thousands of clinical officers, nurses, community health workers and informal assistants. This "task shifting" approach has proven successful in a number of countries including Botswana and Mozambique. However, it has been argued that 'task-shifting' should only be considered only as part of an overall strategy when attempting to address the human resources shortages.
In May 2006 the international community responded to the health worker crisis by collectively creating the Global Health Workforce Alliance (GHWA). Under the alliance, task forces and working groups were established in order to address specific issues such as technical cooperation, migration and resource mobilization. 14 One such group, the Task Force for Scaling up Education and Training for Health Workers, aims to encourage governments and donors to invest in the education and training of health workers in resource-poor countries.
In its 2008 ‘Towards Universal Access’ progress report, the World Health Organization (WHO) stressed the importance of patient retention in HIV-treatment program, which is said was "emerging as a critical issue". The agency expressed concern that the emphasis on recruiting new patients may leave healthcare workers with inadequate resources to ensure that those already on treatment are adhering to their drug regimes.
 It is relatively easy to provide treatment where there is good infrastructure and AIDS-related activities are already taking place, such as in antenatal clinics. It is much harder to move into rural areas and reach people who have little or no contact with health services or community organizations, or to reach marginalized groups such as refugees, prisoners and injecting drug users. Treatment providers need to look for innovative ways to reach the most underserved population groups as they strive for universal access. One example is the use of mobile outreach services to take drugs from treatment centers to outlying communities on a regular basis.
Another underserved population in many cases is children. It is more difficult to treat HIV-positive children because dosages depend on size and weight, so standard pills and capsules are often unsuitable. The best solution may be to provide antiretroviral syrups, but these can be awkward to procure, transport and store (some may require refrigeration). Children often have difficulty coping with swallowing large pills or unpleasant tasting syrups, as well as coping with side effects, and adult supervision may be needed to ensure adherence.

Keywords: HIV, AIDS, Cure, Treatment, Infection, Dating, Positive, Symptoms.

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