AbouZhar, C.

Gilks, C.

Türmen, T.

PubMed

Gilks, Charles

AbouZahr, Carla

Türmen, Tomris

University of Queensland eSpace

HAART in Haiti - Evidence needed

Gilks, C

AbouZahr, C

Turmen, T

the population (e.g. HIV-infected pregnant women)
are another way to advance public health without
overburdening fragile health care systems. Their
experience will show the way forward to the scale-up
of AIDS care in the coming years.
Farmer et al. draw on the lessons and
infrastructure of the directly observed treatment
short course for TB (DOTS) to plan for AIDS care
(4). TB programmes, however, cannot be taken for
granted, nor did they evolve overnight (5–7). The
DOTS strategy, for example, calls for passive case
finding, targeting smear-positive cases, and super-
vised outpatient treatment. These controversial
parameters were set through clinical epidemiology
and operational research, enlightened leadership and
management, and unrelenting advocacy and training.
We are not there yet in AIDS care, though we are not
short of ideas to test.
Until recently, AIDS care research in Africa
and its rationale had been neglected (8). Most non-
experts had assumed that we knewhow to treat AIDS
fromwhat had been done in theOECDcountries (9).
In fact, we are today with AIDS treatment where we
were in 1970 with anti-tuberculosis treatment: there
were many drugs developed a decade earlier, which
were life-saving in the hands of experts. It took over
two decades of sound research to develop a
standardized TB programme (DOTS) that could be
implemented in developing countries (later it was
adopted in OECD countries too (10)). Africa cannot
afford to wait two decades to tackle AIDS. Yet, the
required research has been scant, owing to reserva-
tions about the feasibility of HAART, clinical
overconfidence and ethical paralysis.
Scientific research must be marshalled to ‘‘fast
track’’ the scaling-up of AIDS care beyond pilot
projects. Research can bridge the gap between
increasingly cheaper ARVs and the limited infra-
structure to deliver them inAfrica. Research need not
hold back care. We should learn by doing. Better
action can be informed by research, just as research
priorities should be driven by the imperatives of
action. Competing needs in the fight against AIDS
and poverty demand that we go into comprehensive
care armed with the right weapons. The seeds are
sown. n
1. Jha P et al. Reducing HIV transmission in developing countries.
Science, 2001, 292: 224–225.
2. Perez-Casas C et al. Accessing ARVs: untangling the web
of price reductions for developing countries. Special Report
by Me´decins sans Frontie`res, Geneva, 10 October 2001.
[http://www.accessmed-msf.org/prod/publications.
asp?scntid=9112001121506&contenttype=PARA&]
3. Dye C et al. for the WHO Global Surveillance and
Monitoring Project. Global Burden of Tuberculosis. Estimated
incidence, prevalence, and mortality by country. JAMA, 1999,
282: 677–686.
4. Farmer P et al. Community-based treatment of advanced HIV
disease: introducing DOT-HAART. Bulletin of the World Health
Organization, 2001, 79: 1145–1151.
5. Styblo K et al. Epidemiological and clinical study of tuberculosis
in the district of Kolin, Czechoslovakia: report for the first
4 years of the study, 1961–64. Bulletin of the World Health
Organization, 1967, 37: 819–874.
6. Kochi A. The global tuberculosis situation and the new control
strategy of the World Health Organization. Tubercle, 1991,
72:1–6.
7. Fox W, Ellard GA, Mitchison DA. Studies on the treatment
of tuberculosis undertaken by the British Medical Research
Council tuberculosis units, 1946–1986, with relevant subsequent
publications. International Journal of Tuberculosis and Lung
Disease, 1999, 3 (10, Suppl 2): S231–S279.
8. Fauci A. The promise of research in accelerating AIDS care in
Africa. Meeting on AIDS care research in Africa. Convened by
the Rockefeller Foundation and hosted by Uganda’s Joint
Clinical Research Centre and Makerere University. Kampala,
18–20, April 2001.
9. Guidelines for the use of antiretroviral agents in HIV-infected
adults and adolescents. Washington DC, US Department of
Health and Human Services (DHHS) and Henry J. Kaiser Family
Foundation. Issued 5 February, 2001.
10. KayeK, FriedenTR. Tuberculosis control: the relevance of classic
principles in an era of acquired immunodeficiency syndrome
and multidrug resistance. Epidemiological Review, 1996,
18: 52–63.
HAART in Haiti — evidence needed
Charles Gilks,1 Carla AbouZahr,2
& Tomris Tu¨rmen3
Farmer et al. present a remarkable achievement: the
establishment of a care service for people with HIV/
AIDS in a community of poor displaced people living
in a remote rural area of Haiti (1). The conditions
under which this has been accomplished are
particularly difficult, yet the service has included the
provision of antiretroviral therapy (ART) to 60–
100 people. This has been possible, they argue, by
learning from the history of tuberculosis control and
using a model they have called DOT-HAART
(directly observed therapy with highly active anti-
retroviral therapy), implemented through a team of
community-health workers called ‘‘accompagna-
teurs’’ to supervise therapy.
If the claims of the authors are substantiated,
such a model would have enormous potential for
replication in other resource-poor settings. If, on the
other hand, the authors’ claims are exaggerated, the
potential for doing more harm than good would be
great (and the authors dismissal of the ‘‘spectre of
1 Scientist, Family and Community Health, World Health Organization,
1211 Geneva 27, Switzerland (email: gilksc@who.int). Correspondence
should be addressed to this author.
2 Technical Officer, Family and Community Health, World Health
Organization, Geneva.
3 Executive Director, Family and Community Health, World Health
Organization, Geneva.
Ref. No. 01-1611
1154 Bulletin of the World Health Organization, 2001, 79 (12)
Special Theme – HIV/AIDS
acquired drug resistance’’ is alarming). In the end, the
scientific soundness of the evidence must be the
decisive factor. It is unfortunate, therefore, that the
paper reads more like a statement of positive self-
evaluation than a careful presentation and analysis of
the facts. The paper is instructive not so much for
what it presents as for what it does not reveal. It
makes no serious attempt to consider what really are
the lessons for Haiti, and other countries, if they want
to scale up efforts to provide care to those infected
with HIV/AIDS.
The authors’ main contention is that the
concerns voiced about treating HIV-positive people
with HAART — namely high cost of drugs, lack of
health system capacity to deliver them effectively,
possibility of non-compliance, and risk of drug
resistance — are ill-founded. If we are to be
convinced that this is so, we need better evidence
than that provided in this paper. Let us look briefly at
some important issues the authors did not mention.
First, logistics: what clinical input and staff time
was required to set up and then run this intervention?
Apart from the ‘‘accompagnateurs’’, how many
physician hours were involved? In the real world,
any broadly accessible initiative will have to be
clinical-officer or nurse-practitioner led — there just
are not enough physicians to go around. With rapidly
falling prices, capacity, not cost, will be the big issue.
The human resources and capacities needed to
implement the model intervention need to be very
carefully listed for a real evaluation of their
programme to be made.
Second, entry criteria: ad hoc criteria are used to
start individuals on treatment. What are ‘‘recurrent
opportunistic infections difficult to manage with
antibacterials or antifungals’’? What is ‘‘otherwise
unexplained and significant weight loss’’ compared to
‘‘chronic enteropathy with wasting’’? The severe
neurological complications include peripheral neuro-
pathy which may bemore present in the earlier stages
of disease than other problems. The reliance on
haematological indices including low platelet counts
and ‘‘severe leukopaenia’’ (not defined) suggests
access to automated haematology analysers, which
are not available outside research projects or capital
cities. Also, why have patients with active TB been
excluded?
Third, unforseen benefits: what is the evidence
that the intervention has improved staff morale?
What observations have been made for the group to
form an ‘‘impression’’ that AIDS-related stigma has
been reduced? And how do they relate the increase in
voluntary counselling and testing to this intervention
rather than other changes (there is no control group
and many things have changed over the three years)?
We would all want these benefits to be forthcoming,
but public health physicians need evidence rather
than impressions.
Fourth, costs: how much did it cost to deliver
the drugs? Reference is made to 75–80% of the costs
being for medication — but this is for drugs
purchased in which market and at what price? Eighty
per cent of current US prices for triple drug (perhaps
US$ 8000–10 000) is a lot more than 80% of the
current best (cheapest) prices quoted by Me´decins
Sans Frontie`res and other nongovernmental organi-
zations— around US$ 350 per patient per year. This
incomplete presentation of the facts the group may
well have at hand suggests that the costs are high,
which would then put the intervention in a very
different light. Of course any research initiative will
have additional costs which will be shed if other
nongovernmental organizations start to deliver the
model. But if very costly, how can this intervention
ever be scaled up and replicated, and sustained?
By any evaluation criteria — whether cost-
effectiveness, sustainability, feasibility, or absence of
unintended negative consequences — this success
storymust be classified as non-proven. Yes, we know
with exceptional circumstances, motivation, re-
sources and generous research funding positive
outcomes can be achieved, but replication is some-
thing else entirely. Yes, it is true that with huge inputs
the miracle of ART will produce stunning successes.
And certainly, acting when others have failed to do so
is noble. However, for lack of appropriate design and
scientific evaluation, important lessons that might
have been applied in other settings simply cannot be
drawn from this study. n
1. Farmer P et al. Community-based treatment of advanced HIV
disease: introducing DOT-HAART. Bulletin of the World Health
Organization, 2001, 79: 1145–1151.
1155Bulletin of the World Health Organization, 2001, 79 (12)
Round Table Discussion


HAART in Haiti - evidence needed

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HAART in Haiti--evidence needed.

HAART in Haiti--evidence needed.

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