With millions of dollars coming to Cambodia to fight HIV/AIDS over the next five years and the government’s 2003 goal to expand anti-retroviral drug access to 3,000 people by year’s end, health officials now must decide how best to distribute the medicine.
“There should not be one single model to deliver ARVs. Community-based care could be one of them, but ARVs should also be distributed in hospitals and other clinics,” Dr Veronique Bortolotti, World Health Organization HIV/AIDS care consultant, said of the government’s approach to distributing drugs.
Of the 157,000 people in Cambodia living with HIV/AIDS, 22,000 have developed full-blown AIDS and qualify for anti-retroviral treatment, Bortolotti said.
“Scaling Up Access to Anti-Retroviral Treatment in Cambodia,” a draft report released by the Khana health center earlier this month, found that giving anti-retroviral treatment through hospital staff and clinic-based pilot programs limits the numbers that can be treated and suggests that community involvement and home-based care are critical to the success of the lifetime treatment.
Khana noted that 17 teams providing community-based care for people with HIV/AIDS and other chronic illnesses comprise Phnom Penh’s home-based care network. Care is provided by the staff of government health centers and NGOs, under the supervision of the city’s Health Department. These teams provide basic clinical care, psychological and social support and help with referrals and follow-up treatment.
Khana’s study—conducted in Phnom Penh and Siem Reap in 2002—found that approximately 1,800 people with HIV are supported by home care networks. Each month around 100 new people with HIV join home care programs and between 30 and 40 others die. The limited nature of anti-retroviral treatment, provided through a number of hospital-based pilot programs, is riddled with problems, Khana said.
“The provision and follow-up of anti-retroviral treatment is likely to be jealously guarded by the medical community. Development of a workable compromise will be essential to significant expansion of anti-retroviral delivery,” the report said.
Khana said if large numbers of people are to be treated with anti-retrovirals, a more inclusive model for anti-retroviral delivery support must be established.
The emphasis that Khana is placing on a network of care echoes components of the “Comprehensive Continuum of Care” plan being promoted by the WHO and the National Center for HIV/AIDS, Dermatology, and Sexually Transmitted Diseases, a branch of the Ministry of Health, to fight HIV/AIDS through institutional care, community home-based care, and voluntary counseling and testing.
But some members of the NGO community say anti-retrovirals are too expensive and complicated to be left up to families and friends to distribute and that trained physicians must be involved in drug dissemination.
John Tucker, director of Maryknoll Cambodia’s children’s anti-retroviral program, said relying too heavily on community support can be dangerous. “I don’t think Khana’s idea of having home-based care alone is a good one,” Tucker said. “This is complicated, expensive medicine that must be followed by a physician.”
Dr Jennifer Hines, medical director at Sihanouk Hospital Center of Hope, shares Tucker’s concern. “Cambodia does not have a high level of clinical staff that could manage anti-retrovirals. Without the adequate training of medical staff, it would be premature to use anti-retrovirals on a wide scale,” Hines said.
If anti-retroviral patients do not adhere to a strict drug regime, they run the risk of becoming immune to some types of anti-retroviral or spreading a drug-resistant strain of HIV, Bortolotti said.
“The argument of ‘do we or don’t we’ [give the drugs] is very passe. Now the question is ‘how do we do it?’” said Dr Mandeep Dhaliwal of the Alliance. She said the positive effects of ARVs—improving the quality and length of a person’s life—outweigh the costs.
Three major organizations—Sihanouk Hospital, Medecins sans Frontieres, and Medecins du Monde—currently dominate the field of official anti-retroviral dissemination in Phnom Penh, while countless pharmacies dole out pills to patients without accompanying directions.
“There definitely are not enough trained physicians” to handle the influx of money from donors, said Catherine Quillet, director for Medecins sans Frontieres-France.
The organization has seven doctors trained in anti-retroviral treatment and plans to train two or three more to work with an anti-retroviral program in Kompong Cham in April.
Khana’s report also said the cost of an expensive lifelong treatment like anti-retrovirals could lead to more poverty and inappropriate use.
Still, Khana and its umbrella organization, International HIV/AIDS Alliance, said they believe the benefits of anti-retrovirals outweigh the costs.
Khana said treatment must be expanded and that community involvement is better than no involvement.
Combining physicians’ training with community-based care is crucial to the success of anti-retroviral expansion, said David Wilkinson, a consultant for the HIV/AIDS Alliance.
“ARVs are here already. It’s much better to have a managed environment than an anarchist environment,” he said, referring to the largely uncontrolled distribution of Cambodia’s pharmaceuticals.