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Changes needed to address AIDS as a chronic illness

May / June 2013 | Volume 12, Issue 3

Large group of adults and children, seated on stools and dry dusty ground in circle, huts in background
Photo by Elizabeth Serlemitsos/Photoshare

Health system adjustments needed to treat HIV/AIDS
as a chronic disease are priming developing countries
for the expected surge in noncommunicable diseases,
Dr. Wafaa El-Sadr told NIH.

Improvements to health care systems designed to handle the HIV/AIDS epidemic are priming developing countries to more effectively fight the rising threat of noncommunicable diseases, not least in the remarkable expansion underway in trained physicians, laboratory technicians and other scientists. This observation comes from Fogarty collaborator Dr. Wafaa M. El-Sadr, founder and director of the International Center for AIDS Care and Treatment Programs at Columbia University.

"Despite the enormous challenges, something amazing happened over the past close-to a decade," said El-Sadr, who delivered the James C. Hill Memorial Lecture, named in honor of National Institute of Allergies and Infectious Diseases (NIAID) former deputy director. Responding to the epidemic, health systems scaled up rapidly and by the end of 2012, about 8 million people with HIV/AIDS in developing countries had initiated antiretroviral therapy, she observed.

HIV, as a chronic lifelong disease, demanded a system that offered a continuum of care, rather than the episodic services that were previously the only option in many developing countries where HIV/AIDS was spreading rapidly, El-Sadr said. Countries needed to improve services, raise the quantity and quality of the health care workforce, establish or update information systems, develop ways to obtain medical products, finance the health system and transform leadership and governance.

"Probably at the crux of those important challenges was workforce shortages," she said, citing the example of Lesotho in southern Africa. When HIV prevalence reached 29 percent, the ratio of physicians to patients was 5 per 100,000. In the U.S. at the same time, the HIV prevalence was 0.6 percent and 550 physicians served 100,000 patients.

What followed was a huge investment in training in developing countries, spearheaded by the U.S. President's Emergency Program for AIDS Relief (PEPFAR) and its related program dedicated to increasing medical and scientific expertise, the Medical Education Partnership Initiative (MEPI).

"It was not just didactic training but also new methods for training, including multidisciplinary teams, trying to break down walls that exist between the different disciplines, between nurses and physicians and others, and the importance of mentorship," El-Sadr said.

Among the other many approaches to improving health care systems was expanding infrastructure, including capacity for specimen transfer, laboratory testing, medication procurement, quality assurance and rural outreach. Countries also improved medical records systems and charting tools, trained staff for data collection and management and established ways to assess program quality, she said.

She discussed the spillover effects of improving health care systems for HIV/AIDS into management of other diseases. Although few studies are available to confirm the benefit, she said screening HIV/AIDS patients for co-infections has increased tuberculosis detection rates, which implies quicker treatment and less contagion. And, she said, closer scrutiny of pregnant women to prevent transmission of HIV to babies has contributed to a decline in maternal and child mortality. "Successfully responding to HIV," she said, "is essentially responding to a chronic disease."

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