World AIDS Day 2004 - Expanding treatment - Lessons learned so far
The number of patients treated with ARVs in MSF projects has increased rapidly. Today, MSF treats 150% more patients than in December 2003. MSF has learnt from its experience treating people in resource-poor settings that increasing the number of patients on treatment requires simplification measures such as:
"We have been able to dramatically increase the numbers of patients on treatment by creatively using the existing resources and customising our approach. If we tried to replicate treatment models from Europe and the US, we would never reach patients in rural or slum areas. If we hadn't gone out of hospitals, reached rural out-patient clinics and treated with clinical indications alone, we would have only brought treatment to well-heeled city dwellers." Dr Arnaud Jannin, MSF project in Chiradzulu, Malawi.
- Simplifying treatment regimens Using fixed-dose combinations (several medicines in one pill) reduces patients' pill burden and makes it easier for them to adhere to treatment. As of May 2004, 76% of new patients within MSF projects were starting treatment on a one-pill-twice-a-day regimen. The most frequently used FDC is a triple combination of lamivudine, stavudine and nevirapine, usually sourced from Indian generic manufacturers.
- Simplifying patient inclusion criteria Rather than insisting on CD4 count and other laboratory tests, MSF programmes allow patients in late stage III and stage IV to start treatment based on their clinical signs. Other measures include disbanding selection committees and holding counselling sessions for groups rather than for individuals.
- Free treatment and adherence MSF believes that it is essential to ensure that even the poorest people have access to life-saving treatment. The main cause of treatment interruption in countries where patients are charged for their treatment is the cost. To minimize non-adherence due to inability to pay, nearly all MSF programmes provide ARVs free of charge.
- Decentralising care Offering care closer to communities in need, e.g. at local health clinics, allows patients to start treatment without needing to attend a district or national hospital that might be several hours' away. Devolving responsibility to nurses and clinical officers and training non-medical people as counsellors helps deal with staff shortages and heavy workloads and therefore enables programmes to reach more people.
- Seeking out least expensive quality ARVs By stimulating competition between producers and overcoming patent barriers when necessary, MSF and some governments have brought down costs to below US$300 per patient per year. MSF considers three main sources of quality assurance in deciding which drugs to use in its projects: the National Drug Regulatory Authorities, the WHO pre-qualification project and MSF's internal qualification system that follows standard procedures for pharmaceutical procurement.
- Community participation Many MSF programmes work closely with associations of people living with HIV/AIDS and other community activists to strengthen prevention, bolster voluntary testing and counselling, enhance treatment education and promote adherence to treatment.