HARVARD GAZETTE ARCHIVES

Harvard researchers examined results for patients in the highly active antiretroviral treatment (HAART) program run at the Infectious Disease Care Clinic at Princess Marina Hospital in Gabarone, Botswana. They examined patients who entered the program between April 2001 and January 2002 and followed them through November 2003.

"We found the same effectiveness to AIDS therapies in our patients unable to afford treatment in Botswana, but now being afforded it via a public sector treatment program, as would be seen in patients in the West," said Richard Marlink, professor in the Department of Immunology and Infectious Diseases at the Harvard School of Public Health.

HAART treatment, which uses multiple drugs to attack the disease, has been instrumental in reducing the death rate from AIDS in the United States, European nations, and other developed countries. Implementation of HAART in poorer countries, however, had been limited by the drugs' high cost - as much as $10,000 per person annually in 2000 - and by a lack of health infrastructure.

Drug costs have fallen dramatically in recent years, reaching $140 per person by the end of 2003, but the drugs are still not reaching millions of those who need them. Just 500,000 of the 4.7 million people in need of antiretroviral therapy in sub-Saharan Africa were receiving it as of June 2005, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).

UNAIDS estimates that as many as 6 million people in developing and middle-income nations will die from AIDS in the next two years unless they get access to HAART therapy.

The Botswana study showed that those whose immune systems were most devastated by the disease had the worst outcomes, reinforcing the need to get the drugs to people early enough so their immune systems can still recover, Marlink said.

"It emphasizes to us that expansion of public sector antiretroviral treatment programs in Africa is crucial to creating a setting where people could receive treatment [before] the virus [causes] severe immune damage," Marlink said. "[They'll] do even better with these life-saving therapies."

Marlink said he hopes expanding treatment for AIDS will generate infrastructure improvements that can help with the treatment of other chronic diseases common in Africa.

"The lack of health care infrastructure to care for and treat common chronic diseases in Africa is widespread and tragic," Marlink said. "We should realize that by giving the antiretroviral drugs properly we are improving the overall infrastructure of health care delivery. Our study shows that this improvement in infrastructure is possible and this creates hope for the expansion of health care for other chronic, treatable diseases in Africa."

Sub-Saharan Africa is the region hardest hit by AIDS, and Botswana is among the hardest-hit nations in Africa. At the end of 2003, the disease was thought to infect 37 percent of Botswana's population between the ages of 15 and 49. Deaths due to AIDS are largely responsible for life expectancies falling below 40 years in Botswana and eight other African nations, according to UNAIDS.

The Harvard study was published in the Journal of Acquired Immune Deficiency Syndromes in November. Clinical data for the study was collected from a public-private partnership between the Botswana-Harvard School of Public Health AIDS Initiative Partnership for HIV Research and Education and the Infectious Disease Care Clinic at Princess Marina Hospital. It was funded through a grant from Bristol-Myers Squibbs' Secure the Future initiative.

Lead author William Wester, research associate at the School of Public Health's Department of Immunology and Infectious Diseases, said that a lack of health care infrastructure shouldn't constrain the use of HAART. In rural areas, where there is a shortage of doctors, nurses can be trained to manage the majority of cases, with doctors seeing only the most complicated.

"It is challenging and at times overwhelming to be surrounded by such extensive suffering as a result of the HIV/AIDS epidemic," Wester said. "But it has been a privilege to be in Botswana as it began and is now rapidly expanding the first public [antiretroviral] treatment program in Africa."

Marlink said that the program's success has helped to lessen stigmas surrounding the disease and created a new sense of hope.

"The sheer magnitude of the HIV epidemic, especially in southern Africa, is at times numbing," Marlink said. "[But] the expansion of care and treatment has created a climate of hope in the general population with relation to AIDS in Botswana and has helped to dramatically reduce the stigma associated with this infection and disease in the country."

alvin_powell@harvard.edu

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