Some lessons from MSF's ARV experience

"One pill twice a day": adhering to treatment must be made as easy as possible. For this reason, we are working to have 80% of our patients on triple fixed-dose combinations (FDCs) by January 2004. Nine out of the 10 largest MSF projects are using triple FDCs as their first-line treatment. That is, patients will be taking the three different antiretroviral drugs they need in one pill, twice a day. Taking a smaller number of pills per day facilitates compliance and therefore can encourage better clinical results, and also brings less risk of drug resistance (as it is impossible to take partial doses).

"Decentralize and adapt": treatment protocols must be designed to be implemented in places where there are few hospitals, few doctors and even fewer laboratories. In Chiradzulu, Malawi, MSF has set up mobile treatment clinics at each of the 10 local health centres, making treatment more accessible to communities. Basic patient care and follow up is delegated to nurses and health workers (for medical monitoring) and community counsellors (for education, adherence support and treatment literacy). MSF follows uniform guidelines for treatment minimising use of laboratory tests - in many cases, treatment begins after a positive HIV test and clinical assessment by trained staff. More difficult cases are referred to the district hospital. This has allowed the number of patients under treatment in the district to rise quickly, to a rate of 250 new patients in October 2003 alone.

"Available to even the poorest": the cost of treatment for the patient should never be a barrier. Scaling up the numbers of people on treatment in the poorest countries means that treatment will have to be free for the majority of patients. This is necessary not only for humanitarian reasons but also for medical ones, so that all those who begin treatment can remain on it.

"Price matters": the lower the price of medicines, the more patients can be treated and the more sustainable treatment is in the long term. In MSF projects, the price of first-line treatment ranges from US$270 to US$593 per patient per year. In MSF's experience, crucial factors in bringing about lower prices for ARVs include government commitment (to overcome patent barriers when necessary) and the availability of generic medicines to foster competition.

"Involve the community": the knowledge and participation of patients themselves is key to the success of treatment. At its HIV clinic in Khayelitsha, South Africa, MSF and grassroots treatment advocates have fostered community-based education programs. With community involvement adherence to treatment and prevention efforts are boosted, the taboo surrounding HIV starts to be broken, and a strong civil society pressure is built for an appropriately urgent response to the pandemic.