3.1 Access to medical care

ARVs

In industrialized countries the development of highly active antiretroviral therapy (HAART) has had a dramatic effect on the long-term survival of people with HIV. This has meant that there is great benefit for people with HIV to be aware of their seropositive status so that they can start treatment earlier, thus avoiding HIV-associated illnesses and prolonging their life. In Europe and the United States the death rate from HIV has fallen significantly over the past five years as a result of the availability of HAART (Carpenteret al., 2000⁹⁶). Ongoing counselling has been shown to be an important factor in ensuring adherence (Revsin et al., 1998⁹⁷, Greene et al., 2000⁹⁸).

Preventive therapies

Less costly interventions to reduce the incidence of HIV-associated infections, such as tuberculosis preventive therapy (TBPT), have been shown to reduce the incidence of TB among people with HIV (Mwinga et al., 1998⁹⁹), (WHO/UNAIDS¹⁰⁰). Two studies from sub-Saharan Africa (Godfrey-Faussett et al., 1995 ¹⁰¹, Aisu et al., 1995¹⁰²) have shown that VCT can be an appropriate site for screening and treating people who test seropositive for active TB, and providing TBPT to those without active TB. In Haiti, a community-based programme offering VCT and screening for TB was effective in identifying early TB and instigating prompt and effective treatment (Desormeaux et al., 1996¹⁰³). In Zambia, a pilot project of integrated HIV and TB counselling for families is being developed. Early results demonstrate that this is to be acceptable but longer-term follow-up is awaited (Ayleset al., 2000¹⁰⁴). In Malawi, the Malawi AIDS counselling and resource organization (MACRO) provides VCT at two sites. It also provides TB and STI screening and treatment and family planning. There is considerable demand for these services by people following VCT, even among people who attend VCT for primarily non-medical reasons (Phiri et al., 2000¹⁰⁵).

Other preventive therapies such as cotrimoxazole prophylaxis (Anglaret et al., 1999¹⁰⁶, Wiktor et al., 1999¹⁰⁷ Sassan-Morokro et al., 1998¹⁰⁸) have also been shown to prevent morbidity in PLHA in some settings (seropositive TB patients in Cd’Ivoire and Senegal). Cotrimoxazole is cheap, easy to administer and requires minimal monitoring. UNAIDS has recommended that it should be made more widely available to PLHA.

Family planning services

Referral for other services, such as contraception, can help couples (both seropositive and seronegative) make informed decisions about family planning methods and having children (Pugh et al., 1998¹⁰⁹). In many high-prevalence countries the desire to have children is strong and there have been no significant differences in the uptake of family planning services for seropositive and seronegative women. In Rakai, Uganda, 13% of positive women and 12% of negative women used female-controlled family planning following VCT (Lutalo et al., 2000¹¹⁰).

Ongoing medical care

One of the most valued services offered to people following VCT at Kara, Zambia, was the provision of basic, ongoing medical care for the treatment of HIV-associated infections (Baggaley et al., 1998). Similar findings were evident from The AIDS Support Organization (TASO), Uganda, evaluation.

Complementary medical services

In many countries where ARVs are not available because of cost and lack of laboratory infrastructure PLHA may have symptomatic benefit from complementary/traditional medicines (Gouskov, 2000¹¹¹). However, sometimes counsel-lors may have a role in challenging unrealistic beliefs about complementary therapies or assisting clients in discussing the pros and cons regarding decisions about allocating limited family resources to these therapies.