Positive replication: an MSF background paper for the 2nd IAS Conference on Pathogenesis and Treatment

The challenge of scaling up

Today in developing countries more than six million people urgently need antiretroviral treatment (ART). At the XIVth Conference on HIV/AIDS in Barcelona last year, the World Health Organization (WHO) committed itself to ensuring that 3 million people would be treated by 2005. A third of the time has already elapsed, but there is no evidence to show that we are on track to make this goal. In December 2002, a mere 300,000 people living with HIV/AIDS in the developing world were receiving ART1. Half of these live in Brazil, the only country that has so far implemented universal access to ARVs.

There are many real and perceived barriers to expanding treatment to large numbers of people in the developing world. Among those most often referred to are lack of political will, the high price of ARVs; the lack of trained staff and other elements of healthcare infrastructure; the complexity of treatment protocols and laboratory monitoring.

Médecins Sans Frontières (MSF) believes these should not be viewed as reasons to accept the status quo. Despite facing many of these problems in its HIV/AIDS treatment projects around the developing world, MSF is showing that these barriers are not insurmountable. In July 2002, MSF was treating 2,300 patients in ten countries. At the Barcelona conference, MSF set itself the goal of doubling the number of patients it treated by the end of 2003. Now MSF has 23 projects in 14 countries with 4,447 patients (310 of these are children) receiving ART.

MSF’s most frequently used first-line regimen is stavudine, lamivudine and nevirapine and fixed dose versions of these combinations are being used in a majority of projects. In MSF projects the price of first-line therapies ranges from US$277 (Cameroon) to US$593 (Ukraine) per patient per year.

MSF ART projects are on a relatively small scale and cannot possibly reach the multitude of people in need across the developing world. Nonetheless, lessons can be learned from these experiences. This document presents basic facts and figures about MSF ART projects, and highlights some lessons MSF has learned in three of its projects: centralised procurement in Cameroon, decentralisation of care in Malawi, and community involvement in South Africa.

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