Global Policy Forum

By Lawrence K. Altman

The World Health Organization called on developing countries yesterday to train and organize 100,000 health care and nonprofessional workers to carry out its plan to begin delivering antiretroviral drugs to three million AIDS patients by the end of 2005. The organization, a United Nations agency, said 6 million of the 40 million people infected with the AIDS virus were in immediate need of antiretroviral treatment, but that only about 480,000 were receiving it.

The new program, which the organization said would cost at least $5.5 billion, is intended to reach half those in need by the end of 2005 — two million more than would be reached by then without such a program.

In issuing a more detailed framework for its program, to coincide with World AIDS Day today, the organization also recommended four combinations of antiretroviral drugs that countries could use to start treatment. The list was vastly simplified from the 35 possible combinations the organization had recommended previously. All four combinations have been proved effective, though none include the powerful protease inhibitor drugs that are often prescribed in the United States and other wealthy countries. AIDS specialists whom the organization consulted recommended keeping Protease inhibitors in reserve for patients who did not respond to the first-line drugs, officials from the organization said in a telephone news conference. They said that with experience they would review treatment regimens to determine if revisions were necessary.

By involving about 100,000 workers, the organization's anti-AIDS plan is the most ambitious of the many that a number of countries have advanced in recent months and raises practical and ethical issues.

The W.H.O. made its announcement at a time when former President Bill Clinton helped broker an agreement to reduce the price of antiretroviral drugs to more affordable levels for poor countries and when countries like India and South Africa have said they will expand their programs to treat AIDS.

In issuing its plan, the W.H.O. said it hoped to provide the technical details of what was needed to treat people to extend their lives. The organization's plan calls for rapidly expanding programs to train workers and improve services, not adding new ones. "We cannot in a two-year period build new health systems," said Dr. Charles Gilks, the leader of the organization's new AIDS treatment program.

But with insufficient supplies of drugs, even a successful W.H.O. program will create enormous ethical issues for countries in deciding which patients to treat. "Clear decisions will have to be made where programs will be started, and that will involve winners and losers," Dr. Gilks said.

Dr. Julian Fleet, a senior policy adviser for the United Nations AIDS program, said "the question of who will receive antiretroviral drugs is really a question of who shall live." Because making such decisions involves broad societal issues, the W.H.O. is planning a meeting at its headquarters in Geneva in a few weeks to help countries answer that and other thorny questions.

The organization's plan challenges the 34 countries with the highest infection rates to rapidly train workers to accelerate the integration of AIDS treatment in their health care programs. Many countries with the largest numbers of people living with H.I.V./AIDS have very few doctors or other trained health workers, the organization said. Many have died from untreated AIDS, while others have moved to wealthier countries.

The W.H.O. said the involvement of communities and community workers was essential to its plan. The training programs are expected to enable health workers to evaluate patients and make sure they take their medicine.

"Nothing is as rewarding" for someone who has been trained, Dr. Gilks said, than "to be able to immediately use those skills to watch somebody who is dying of something they were powerless to intervene with, and see that individual suddenly restored to life." But he said workers could become frustrated if they were trained and had no drugs to deliver or kits to test for the virus.

Many countries, medical schools, private groups and other organizations have started AIDS programs in heavily infected countries. The numbers of programs have reached the point where better coordination is needed to avoid duplication of research, training and treatment efforts, Dr. Peter Piot, the director of the United Nations AIDS program, said in a recent interview.

The W.H.O.'s recommended drug combinations for simplified AIDS treatment are: Stavudine (d4t), lamivudine (3TC) and nelfinavir; AZT, lamivudine and nelfinavir; Stavudine, lamivudine and efavirenz; and AZT, lamivudine and efavirenz. Each country will choose based on a patient's needs and the availability and suitability of a particular regimen.

The strategy also recommends the use of quality-assured "fixed dose combinations" or blister packs of pills when available. In choosing drugs other than protease inhibitors, W.H.O. is not "pursuing second-line therapy in resource-poor countries," Dr. Gilks said. "We are enabling treatment to be widely accessible in places where it is not accessible and people are dying."

The organization's plan also simplifies monitoring by substituting easy-to-use tests like body weight and color-scale blood exams for the more complicated and expensive tests to measure the amount of CD-4 immune cells and H.I.V. in the blood used in rich countries. In poor countries, the W.H.O. said, properly trained health workers can combine the simplified tests with clinical evaluations to effectively monitor the progress of AIDS, the effectiveness of treatment and its side effects.

The W.H.O. plan will require $5.5 billion in the next two years. But officials said they did not know exactly how much had already been committed. One reason is that some countries have made pledges but have not set aside the money. "The lack of H.I.V. treatment is without a doubt a global emergency," Dr. Piot said. "We firmly believe that we stand no chance of halting this epidemic unless we dramatically scale up access to H.I.V. care. Treatment and prevention are the two pillars of a truly effective, comprehensive AIDS strategy."

FAIR USE NOTICE: This page contains copyrighted material the use of which has not been specifically authorized by the copyright owner. Global Policy Forum distributes this material without profit to those who have expressed a prior interest in receiving the included information for research and educational purposes. We believe this constitutes a fair use of any such copyrighted material as provided for in 17 U.S.C § 107. If you wish to use copyrighted material from this site for purposes of your own that go beyond fair use, you must obtain permission from the copyright owner.