STANFORD, Calif. - When there are millions of patients clamoring for anti-AIDS drugs and precious little to go around, who decides which patients go to the front of the line? The answer, says Stanford AIDS researcher Dennis Israelski, MD, is relatively simple: the affected community.
Israelski, clinical professor of infectious diseases at the School of Medicine, is medical director of the nongovernmental organization, AIDS Empowerment and Treatment International, or AIDSETI, a network of 23 associations in 14 sub-Saharan African and Caribbean countries, whose mission is to support the scale-up of sustainable systems of HIV/AIDS health care through community empowerment.
"I believe if you give the affected communities the necessary resources, appropriate tools and training, it will do a better job in providing care and treatment than approaching the problem from the top-down," said Israelski, who is also the medical director of the AIDS Program in San Mateo County, Calif.
AIDSETI's cohort is estimated to be 100,000 people living with HIV/AIDS. In a new, small-scale study, to be presented Aug. 17 at the International AIDS Conference in Toronto, Israelski and his colleagues found that the group has been effective in distributing antiretroviral drugs to the patients who need them most.
"What we found in our initial evaluation indicates an equitable distribution of medications, based on gender and severity of illness," said Seble Getachew Kassaye, MD, a postdoctoral scholar in infectious disease at Stanford and first author of the study. Moreover, patients who received drugs showed substantial increases in their CD4 counts, a measure of immune system function, the researchers found.
Given the results, researchers believe the program could be a model for scaling up antiretroviral treatment in more poor nations, alongside other treatment programs.
In 1999, when AIDSETI was founded, there were few programs providing care for people living with HIV and AIDS in Africa, and only a limited supply of drugs were being distributed - without clear guidelines or medical supervision, Israelski said.
AIDSETI organizers seized on the concept of community-driven development, a well-known model of international development championed by AIDSETI cofounder Hans Binswanger, a World Bank economist. He had originally advocated such an approach to combat the effects of poverty, but he and others who launched AIDSETI adapted it for the first time for use in a health-care setting, Israelski said.
AIDSETI organized a network of associations of people living with HIV/AIDS throughout sub-Saharan Africa and the Caribbean. It provided antiretroviral treatment and helped to disseminate medical guidelines for the effective management of such care - before the advent of the major international funds to combat HIV/AIDS. The associations offer other services as well, such as nutritional support, psychological counseling, legal aid and help starting income-generating activities.
Patients treated through the associations must meet standard clinical criteria, including reduced levels of CD4 immune cells, to qualify for anti retroviral therapy. Still, there are long waiting lists for these precious, life-prolonging drugs. Under AIDSETI guidelines, first priority is given to people in the community who are actively involved in promoting HIV prevention and treatment messages. The next in line are children of community activists who have died, foster parents, essential health-care workers and patients most likely to adhere to a treatment regimen.
To gauge the effectiveness of the program, the researchers examined data for more than 1,500 of the group's patients in four countries: Burkina Faso, Kenya, Tanzania and Zimbabwe. The patients, 1,035 women and 491 men, had been enrolled in the program between 2003 and 2005. The number of patients on antiretroviral therapy doubled during the two-year period, with 29 percent of participants on the medications by the spring of 2005.
About one-third of the patients had undergone testing for CD4 counts, with results showing significant improvements in their immunologic status.
Israelski said the effectiveness of the program varies from country to country. In the study, patients in Zimbabwe and Kenya showed significant improvement over time. The trend was not as clear in Tanzania and Burkina Faso, where significant progress has been made since the study with World Bank funds supporting the roll out of antiretroviral treatment at six sites.
Israelski said one of the most robust AIDSETI groups is in Burundi, where there is nearly universal access to antiretroviral treatment despite more than 10 years of civil unrest. "This has been a favored model by the government in Burundi to meet the challenge of providing access to quality care and treatment of HIV/AIDS," he said.
The AIDSETI organization is an extension of Israelski's experience in San Mateo County, where he has observed the benefits of bottom-up over top-down approaches. "Community empowerment works to improve the life of stigmatized and marginalized groups, whether it's in East Palo Alto or Ouagadougou," Israelski said.
In addition to Kassaye, his collaborators in the study are F. Ndayishimiye, I. Tiendrebeogo, A. Herman, L. Francis, D. Onyango, R. Machekano and A. Sall.
Stanford University Medical Center integrates research, medical education and patient care at its three institutions - Stanford University School of Medicine, Stanford Hospital & Clinics and Lucile Packard Children's Hospital at Stanford. For more information, please visit the Web site of the medical center's Office of Communication & Public Affairs at http://mednews.