AIDS care is learnt by doing it.

There is consensus that prevention is the most important strategy to halt the AIDS pandemic (1), and introducing an HIV vaccine is our ultimate tool for doing this. However, the inconsistent success of prevention programmes, and the absence of effective vaccines now and in any near future, provide ample grounds for looking more seriously at care for AIDS patients in resource-poor countries. We have reached a point of no return, moving from the if and the when of effective care to the how. Reasons for taking up the challenge of care now include the following. First, the sheer magnitude of the global AIDS crisis. Silently infected before, millions of people living with HIV/AIDS are now falling sick and dying. Second, there is moral outrage over this tragedy when therapy exists for those who can afford it. Public opinion now demands a shift from unmitigated suffering to hope. Third, indifference to such suffering reduces the credibility of prevention efforts. Treatment is thus an essential component of the AIDS control continuum. Fourth, a 97% reduction in antiretroviral (ARV) prices (2) and hospital cost savings in Brazil have made previous arguments over affordability obsolete, and given rise to confidence that AIDS care in poor countries is not only feasible but inevitable. Fifth, mounting pressure -- politically and even legally -- on multinational pharmaceutical companies, local governments, and the international community is opening the door to new resources. Universal access to highly active antiretroviral therapy (HAART) for millions of people is not feasible today, but doing nothing is unacceptable. One parallel with tuberculosis (TB) is that a much simpler and curative regimen reaches only 25% of patients despite a decade-long campaign (3). AIDS care is daunting by comparison. Talking of billions of dollars is easy compared with the demands of setting priorities (e.g. what regimen, where to start) and raising and allocating vast resources. But if the risks are high, so too are the opportunities. Moving forward, there are at least two steps we need to take before going full speed ahead: demonstration projects, and targeted research. Small pilot projects by dedicated physicians, such as the Partners in Health work in Haiti (4), bring hope and suggest the feasibility of AIDS care in poor countries. Newer models designed to target a specific subset of 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 supervised 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 knew how to treat AIDS from what had been done in the OECD countries (9). …