**U.S. Agency for International Development**

**Highlights from the XIV International AIDS Conference**

**July 31, 2002**

# "Caring for People Living with HIV and AIDS"

***Paul DeLay of USAID*** opened the discussion by describing the
sobering and draining effects of attending the Barcelona conference, not
only because of the quantity of information but also because of the
content presented, such as the demographic impact data USAID released
during the conference. One of the positive stories to come out of the
conference was in HIV/AIDS care and treatment, and USAID is very excited
about the initiation of combination antiretroviral (ARV) therapy in
three countries announced at Barcelona. The effective use of this
therapy in low-resource settings has been demonstrated in Haiti, Uganda,
and Brazil, so the new programs will begin to deliver treatment services
and build the capacity to scale up the safe and effective provision of
these drugs. This scaling up will use existing infrastructure and
available settings, working very closely with governments, communities,
and particularly with affected and infected persons. Programs will be
adapted for each country and expand the number of patients and locations
as resources permit and experience provides a better understanding of
the best way to do it.

***ARV Therapy Start-Up.** **Eric van Praag of Family Health
International*** focused on two aspects from Barcelona -- key messages
distilled from the discussions of care and USAID's initiative to
implement ARV treatment in Ghana, Kenya, and Rwanda (and hopefully in
Cambodia soon as well).

One key message was that the treatment vs care dichotomy is a false
dichotomy, because ARV treatment will not cure HIV infection.
Eradication of HIV with ARV therapy is impossible, but lifelong
suppression of the viral load is possible. This will ensure
imunocompetence and enable infected persons to lead socially and
economically productive lives. Another key message was that ARV
treatment does not eliminate the need for care. There is a continuous
need to address stigma, social and psychological issues, and, most
importantly, the needs of the vast majority of infected and ill people
for whom ARV treatment will not be an option for another five or ten
years. These people will need psychosocial support, opportunistic
infection management, preventive therapies, palliative care, and home
care. Another key and clear message was that HIV management with ARV
drugs in poor communities is very feasible, although it is not easy,
especially with the obstacles posed by stigma and marginalization.
Finally, Barcelona provided a consensus that the prevention--care debate
is over. The distinction is misleading, and cost-effectiveness
comparisons of prevention and treatment do not respect human factors or
the dynamics of declining costs over time.

Regarding USAID's ARV treatment initiative, the program in Ghana,
starting from scratch in November 2001, has progressed to care and
treatment training in August 2002 and will initiate treatment in
December 2002. Voluntary counseling and testing (VCT) activities are the
entry point to care. In Rwanda, where some district-level VCT services
have been in place since 1998--99, ARV treatments will begin in
2002--03. In Kenya, assessment of the care and drug delivery systems is
underway, and the implementing partners hope to know enough about which
elements to strengthen by September or October so that ARV treatment can
be implemented by December or January.

***Three Themes. John Stover of the Futures Group International***
addressed three themes coming out of Barcelona. The first was unfilled
expectations. Many participants were wondering why more is not happening
and were impatient with the pace of progress. There is an emerging
consensus among program professionals and donors about the need to get
on with the business of doing prevention and care together. Even when
WHO announced an ambitious program to provide 3 million people in low-
and middle-income countries with ARV therapy by 2005 (about 50 percent
of the forecast need, up from 2 percent today), they were challenged to
cover 6 million (the forecast need) and even 12 and 18 million (double
and triple the forecast need) -- in other words, to go far beyond what
is required -- out of a sense of impatience with unmet expectations.

The second theme was the question of where we are today -- what level of
coverage for various prevention and care services do we have today as a
way of measuring progress toward the goals set for 2005, 2007, and so
on? During the conference, WHO released a report called "The Health
Sector Response to HIV/AIDS: Coverage and Selective Services in 2001."
The report listed three levels of care for people living with HIV/AIDS
-- essential, intermediate, and advanced -- and reported that about
two-thirds of the people living with HIV/AIDS in low- and middle-income
countries are not receiving even the most basic package of care. Only
about 10 percent live in countries that even provide the intermediate
and advanced care packages.

The third theme was the role of the commercial private sector in
improving employee care and providing benefit coverage for employees who
have HIV/AIDS. There are some indications that businesses are shifting
the burden of HIV care from themselves to the public sector or to
individuals, but there are also heartening examples of multinational
companies, such as Heineken, that have added ARV treatment to their
employees' health coverage. Heineken wrestled with some difficult
decisions about providing this benefit, such as including employees'
family members and the duration of coverage, but in the end decided it
could afford to provide a very inclusive package. Few people have taken
advantage of the program, however, since it began late last year,
because they do not want to be tested for HIV infection. Despite
Heineken's efforts to create a nondiscriminatory, nonstigmatizing
environment, employees cannot quite believe they will not lose their
jobs if they test positive, and they are unwilling to take the perceived
risk of losing a good job with a multinational for something that seems
like a future benefit.

***Scaled-Up Care and Support in South India. Chris Castle of the
International HIV/AIDS Alliance/Horizons*** described the YRG CARE
project in South India, which has worked since January 2000 to expand
services in four sites. The project has identified networking, cost
recovery, and incremental, strategic development that avoids duplication
and competition among providers as essential elements for
sustainability. The main challenges to success were stigma and
discrimination and the failure of high-risk populations to come forward
because of a perceived lack of services. Once care and support services
are strengthened, these populations show a greater interest in and
demand for prevention, and prevention interventions can then be better
targeted for them.

## Questions and Comments. Subjects included the difficulty of scaling up vs implementing pilot projects, the role of incentives in employee HIV testing, evidence of the link between improved care and improved prevention, prevention of opportunistic infections, and the role of nutrition in care.