|Access to Drugs (UNAIDS, 1998, 12 p.)|
Improving access to drugs for people living with HIV presents challenges on a variety of levels. Most countries face the following challenges to some degree, though the mix and intensity of each challenge varies from country to country.
Cost of treatment
The cost of drugs poses the greatest single challenge to individuals and to health-care systems. Although the price of the most expensive proprietary drugs (such as triazole antifungals, drugs to treat MAC and CMV infections, and antiretrovirals) will likely decrease in the years to come through the effects of competition and expiring patents, many products will probably remain financially out of reach for the majority of people living with HIV/AIDS.
Rational selection of drugs by health sector
Rational selection of a cost-effective list of drugs requires not only knowledge of drug prices and applications, but also of the health sector's capacity to use those drugs efficiently. Even before these questions are asked, however, decision-makers need detailed knowledge about morbidity (i.e. symptoms and diseases) among people living with HIV/AIDS. This is difficult when the health sector faces problems such as: limited diagnostic capacity; inadequate record-keeping; data collection focused on reportable conditions and hospitalized patients (this tends to under-report less severe conditions and those that occur among outpatients).
Inadequate health-care infrastructure
In some countries, health-care infrastructure (chiefly the physical infrastructure of health-care facilities, both public and private) is too sparse to ensure adequate usage of drugs even if these drugs were to be imported at no cost. It will be a challenge in each country to objectively assess and prioritize the possible medical and public health interventions in the existing infrastructure (as well as to assess country's needs), and to decide where it should be strengthened or expanded.
Distribution and administration
As with infrastructure, many countries do not have adequate distribution systems or sufficient trained personnel to permit drugs to get to the people who need them. Improvements may be required in a variety of areas including transport systems, drug handling, stock control, and record-keeping.
Rational drug use by care providers and clients
Proper use of most drugs for HIV requires training and information for doctors, nurses, pharmacists, and other care providers. It also requires knowledgeable clients since about 70 to 80% of health care takes place in the household rather than in hospitals or clinics, with people making their own decisions about which drugs to use. In many settings, however, reliable information is not available and drug use may therefore be strongly influenced by uninformed friends and relatives, traditional healers and unqualified entrepreneurs.
The priority given to AIDS-related needs in national policy and health budgets is partly the result of analysis, taking into account factors such as prevalence of HIV, its impact on society, and other important needs faced by the country. However, it is also highly dependent on how much of a voice people infected or affected by HIV (i.e., not just people living with HIV but their families, friends and support network) have in the decision making process. In the absence of pressure from them it is likely that their needs will be given a low priority. This is a particular challenge in places where the social consequences of disclosing HIV infection are onerous, and where independent political advocacy is difficult.
Ethical considerations about rationing scarce drugs
Since full access to all drugs needed by people living with HIV is not realizable in the short term in the vast majority of countries, some types of drugs will need to be rationed. This inevitably gives rise to both practical and ethical questions. For instance, what criteria will be used to decide whether an infected person receives treatment or not? (For further information see module 9 of the WHO Guidelines listed in the Selected Key Materials.)