HIV/AIDS programmes should focus on improved access

Editor—GlaxoWellcome's recent move to reduce the cost of antiretroviral drugs in sub-Saharan Africa,¹ although to be applauded, is unlikely to have an impact on most of those infected with or affected by HIV/AIDS in sub-Saharan Africa. The cost of monitoring and treating patients with AIDS with antiretrovirals is high; even an antenatal screening programme creates considerable problems, with extra laboratory and counselling services needed and the risk of a hostile community reaction. Maintaining long term prophylaxis even with effective drugs such as isoniazid and co-trimoxazole may also be difficult in more remote areas (as it is already with the treatment of other long term conditions such as hypertension and schizophrenia).

National HIV/AIDS programmes should be balanced in the needs of both the community and the individual, and in prevention and care. Patience is needed in effecting changes in the perceptions of a community in relation to HIV/AIDS, from panic and denial through to acceptance. This can be difficult in the face of so much death and suffering. Much remains to be done in improving access to information to empower poor people living in remote areas.

There is also an urgent need to improve access to condoms; strengthen health programmes such as directly observed treatment, short course (DOTS) for tuberculosis and the syndromic approach to sexually transmitted disease treatment; and improve practical support to communities caring for those who are sick and the orphans.

Much good will and money seems to be available, but this often does not reach where it is needed because of concerns regarding lack of sustainability, bureaucratic administration, and communication difficulties. Maybe no effective solution to the HIV/AIDS epidemic will exist until a medical breakthrough is made, such as the development of a vaccine.

The epidemic has been around long enough for the effects to be obvious to people even in remote areas. This allows health workers to be more successful in confronting traditional beliefs, such as those about gender roles and traditional medicine, in prevention campaigns. All partners working with prevention programmes should maintain their momentum through what can sometimes seem a difficult damage limitation exercise. They should use the more positive community attitudes towards HIV/AIDS issues seen in many sub-Saharan countries to develop evidence based programmes that focus more on improved access and less on sustainability.