Africans advocate antiretroviral strategy similar to DOTS

AIDS experts suggest community health workers should help in the delivery of antiretroviral drugs

Charles Wendo reporting from Nairobi

As Africans become hopeful that antiretroviral drugs will become more widely available, health experts are advocating for a delivery system similar to the DOTS approach to tuberculosis.

At the International Conference on AIDS and Sexually Transmitted Infections in Africa (ICASA) in Nairobi, Kenya (Sept 21-26), delegates observed that there are too few doctors to effectively treat and monitor the large numbers of AIDS patients in Africa. For example, the number of physicians available per 100 000 people varies from three in Burkina Faso, Chad, and Eritrea to 56 in South Africa, according to UNDP's Human Development Report 2002.

Generally, experts and service providers agree that people without medical training should be recruited and trained to help in the delivery of antiretrovirals. However, their views vary on what role this cadre of health workers should have.

Violet Kimani, professor and head of the department of community health at the University of Nairobi, said people with secondary school education could be trained to deliver antiretroviral drugs and information in communities. These community health workers would take antiretrovirals to the homes of AIDS patients and report to physicians. "The community-based approach is the answer. It is the only way. We will never have enough professionals to look after our people", she said. "These people are sick and can't move. In most cases they don't have transport. The drugs should be taken to them."

Kimani said the concept of community health workers is not new. It has worked before and there is no reason why it should not work with AIDS. "I think antiretrovirals need surveillance. Patients should be checked at regular intervals. But the delivery should be done by community health workers", she said.

Miriam Were, chair of the National AIDS Control Council of Kenya, said tests such as CD4 count and viral load, which are needed before beginning antiretroviral therapy, cannot be done in communities. Therefore to begin with, patients will have to go to hospital. "Once a person has started treatment the rest can be done at community level", she said.

Fred Wabwire-Mangen, professor of public health and one of the directors of the Academic Alliance for AIDS Care and Prevention in Africa, agreed that community health workers are essential in antiretroviral programmes. However, he thinks their job should be restricted. "The decision of who should take antiretrovirals, what type of antiretrovirals, and when to change the combination is a highly technical decision that should be made by a qualified doctor", he said.

Wabwire-Mangen said that once a physician has issued the prescription, nurses and clinical officers can monitor the patients for their response to treatment as well as for side effects. These nurses and clinical officers would then report to a physician if anything went wrong. The role of community health workers, said Wabwire-Mangen, should be to sensitise the public, and to educate and counsel AIDS patients. They should also encourage patients to take up antiretroviral therapy, monitor them to ensure that they take the drugs, and encourage them to return to hospitals for check-ups.

But Major Rubaramira Ruranga, the national coordinator of People Living with AIDS, and one of the first Ugandans to take antiretrovirals--in 1987--does not agree that the drugs would be too complicated for community health workers. "That is the usual fantasy. They [antiretrovirals] are drugs like any other drugs. You only need to give clear instructions. People need to be told where to go when they get problems", he said.

Peter Mugyenyi, a doctor who pioneered antiretroviral therapy in Uganda, agreed that community-based treatment is the best approach. "With good training, the use of antiretrovirals is not that complicated. It has been exaggerated", he said.

Mugyenyi said a community-based antiretroviral programme in Kange, Haiti, had been successful, with 100% compliance. One patient companion monitors six to ten patients. He delivers their daily doses of antiretrovirals and ensures they take it. Such a programme, he said, would be applicable in Africa once the drugs become widely available.

He said that with good training even clinical officers can prescribe antiretrovirals as long as physicians supervise them. "We are talking of 30 million people who are infected with HIV in Africa, and this continent has the lowest number of doctors. So anyone who says strictly antiretrovirals should be given by physicians and cover that number is not wishing the programme success", he said.