An estimated forty million people carry the human immunodeficiency virus (HIV), and five million more become newly infected annually. In recent years, many HIV-infected patients in wealthy nations have enjoyed significantly longer, good-quality lives as a result of antiretroviral therapy (ART). However, most infected individuals live in the poorest regions of the world, where ART is virtually nonexistent. The consequent death toll in these regions--especially sub-Saharan Africa--is begetting economic and social collapse.

To inform the multiple efforts underway to deploy antiretroviral drugs in resource-poor settings, the Institute of Medicine committee was asked to conduct an independent review and assessment of rapid scale-up ART programs. It was also asked to identify the components of effective implementation programs.

At the heart of the committee's report lie five imperatives:

• Immediately introduce and scale up ART programs in resource-poor settings.
• Devise strategies to ensure high levels of patient adherence to complicated treatment regimens.
• Rapidly address human-resource shortages to avoid the failure of program implementation.
• Continuously monitor and evaluate the programs to form the most effective guidelines and treatment regimens for each population.
• Prepare to sustain ART for decades.

Contents

• THE NATIONAL ACADEMIES
• COMMITTEE ON EXAMINING THE PROBABLE CONSEQUENCES OF ALTERNATIVE PATTERNS OF WIDESPREAD ANTIRETROVIRAL DRUG USE IN RESOURCE-CONSTRAINED SETTINGS
• BOARD ON GLOBAL HEALTH
• Reviewers
• Preface
• Acknowledgments
• Synopsis
• Executive Summary
• 1. Introduction
  • CHALLENGES AND OPPORTUNITIES: ANTIRETROVIRAL THERAPY IN RESOURCE-CONSTRAINED SETTINGS
  • BEYOND THE BIOMEDICAL MODEL
  • GOALS OF THE STUDY
  • STUDY APPROACH
  • ORGANIZATION OF THE REPORT
  • REFERENCES
• 2. Opportunities and Challenges
  • CURRENT EFFORTS
  • COORDINATING THE GLOBAL RESPONSE
  • FISCAL SUSTAINABILITY
  • ETHICAL ISSUES
  • REFERENCES
• 3. Lessons Learned
  • THE PROBLEM OF RESISTANCE
  • IMPLICATIONS OF RESISTANCE FOR SCALE-UP
  • LEARNING BY DOING: SCALE-UP AROUND THE WORLD
  • REFERENCES
• 4. Principles of Scale-up
  • REDUCING STIGMA AND DISCRIMINATION
  • IDENTIFYING POINTS OF ENTRY
  • CLINICAL PRINCIPLES
  • THE IMPORTANCE OF ADHERENCE
  • INTEGRATION OF PREVENTION AND TREATMENT
  • PALLIATIVE CARE FOR AIDS PATIENTS IN DEVELOPING COUNTRIES
  • REFERENCES
• 5. Managing Scale-up of Antiretroviral Therapy
  • BUILDING HUMAN RESOURCE CAPACITY
  • DEVELOPING A SUSTAINABLE WORKFORCE
  • SECURING AND DELIVERING EFFECTIVE DRUGS
  • MONITORING AND EVALUATION
  • REFERENCES
• 6. The Path Forward
  • OPERATIONS RESEARCH: CLOSING THE GAP BETWEEN RESEARCH AND CARE
  • APPLIED CLINICAL RESEARCH
  • BEHAVIORAL RESEARCH
  • ENSURING SUSTAINABILITY ALONG THE PATH FORWARD
  • REFERENCES
• Appendix A Information Gathering Workshop Agenda
• Appendix B Primer on Human Immunodeficiency Virus, Acquired Immune Deficiency Syndrome, and Antiretroviral Therapy
• Appendix C Scaling Up Antiretroviral Therapy in Resource-Limited Settings: Treatment Guidelines for a Public Health Approach
• Appendix D Human Ethical Issues Arising in ARV Scale-up in Resource-Constrained Settings
• Appendix E Human Resource Requirements for Scaling-up Antiretroviral Therapy in Low-Resource Countries
• Appendix F Glossary and Acronyms
• Appendix G Committee and Staff Biographies

This study was supported by Contract No. NO1-OD-4-2319 between the National Academy of Sciences and the U.S. Department of Health and Human Services, and contract 32467 between the National Academy of Sciences and the Bill and Melinda Gates Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.