title: The WHO public-health approach to antiretroviral treatment against HIV in resource-limited settings.
abstract: WHO has proposed a public-health approach to antiretroviral therapy (ART) to enable scaling-up access to treatment for HIV-positive people in developing countries, recognising that the western model of specialist physician management and advanced laboratory monitoring is not feasible in resource-poor settings. In this approach, standardised simplified treatment protocols and decentralised service delivery enable treatment to be delivered to large numbers of HIV-positive adults and children through the public and private sector. Simplified tools and approaches to clinical decision-making, centred on the "four Ss"--when to: start drug treatment; substitute for toxicity; switch after treatment failure; and stop--enable lower level health-care workers to deliver care. Simple limited formularies have driven large-scale production of fixed-dose combinations for first-line treatment for adults and lowered prices, but to ensure access to ART in the poorest countries, the care and drugs should be given free at point of service delivery. Population-based surveillance for acquired and transmitted resistance is needed to address concerns that switching regimens on the basis of clinical criteria for failure alone could lead to widespread emergence of drug-resistant virus strains. The integrated management of adult or childhood illness (IMAI/IMCI) facilitates decentralised implementation that is integrated within existing health systems. Simplified operational guidelines, tools, and training materials enable clinical teams in primary-care and second-level facilities to deliver HIV prevention, HIV care, and ART, and to use a standardised patient-tracking system.
authors.affiliation: Department of HIV/AIDS, World Health Organization, Geneva 1211, Switzerland. gilksc@who.int
authors.forename: Charles F
authors.initials: CF
authors.lastname: Gilks
authors.forename: Siobhan
authors.initials: S
authors.lastname: Crowley
authors.forename: René
authors.initials: R
authors.lastname: Ekpini
authors.forename: Sandy
authors.initials: S
authors.lastname: Gove
authors.forename: Jos
authors.initials: J
authors.lastname: Perriens
authors.forename: Yves
authors.initials: Y
authors.lastname: Souteyrand
authors.forename: Don
authors.initials: D
authors.lastname: Sutherland
authors.forename: Marco
authors.initials: M
authors.lastname: Vitoria
authors.forename: Teguest
authors.initials: T
authors.lastname: Guerma
authors.forename: Kevin
authors.initials: K
authors.lastname: De Cock
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000009:adverse effects / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D002648:Child; D002675:Child, Preschool; D003906:Developing Countries; D004347:Drug Interactions; D015658:HIV Infections / Q000145:classification / Q000188:drug therapy / Q000276:immunology; D006801:Humans; D007223:Infant; D011634:Public Health; D012720:Severity of Illness Index; D014944:World Health Organization
chemical_list: D044966:Anti-Retroviral Agents