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Who Pursues Ambitious AIDS Treatment Plan for Poor

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The World Health Organization and doctors in Africa and Asia have quietly but quickly begun identifying ways to treat 3 million poor people in the next two years with complicated AIDS therapies, a feat that would be unparalleled in scope in the history of public health.

The WHO plans would increase tenfold the number of HIV and AIDS patients in developing countries who currently receive treatment. The sudden urgency by health officials follows two decades of virtual inaction for treatment of AIDS among the poor. The current press stems from an ambitious goal set by the WHO to increase treatment by 10 times by 2005, and it will draw upon important groundwork done by private groups in Haiti, Peru, and several countries in Africa and Asia.

The ideas being discussed at WHO offices in Geneva and in several African countries include: enlisting health workers or even family friends - instead of doctors or nurses - to oversee HIV and AIDS patients on a regular basis; training thousands of people as caregivers in 10-day or monthlong sessions; and writing up the basic treatment protocols for antiretroviral drugs in an effort to give pharmaceutical companies for the first time clear marching orders on what drugs to produce on specific timetables.

Currently, 300,000 people with HIV or AIDS receive antiretroviral treatment in the developing world, and 50,000 of them are in Africa, according to United Nations estimates. Health officials estimate 4.1 million people should be receiving the lifesaving antiretroviral drugs and a total of 6 million will need them by 2005.

Without treatment, health officials say, millions of people will die from AIDS, surpassing the toll from the black plague of the 14th century. Epidemiologists warn that many southern African countries, in particular, are about to enter a ``death spiral,'' in which the number of AIDS fatalities will rapidly increase beginning this year and lasting until 2009, when the numbers will begin to drop only because so many people will have already died.

Underscoring the need to act soon, WHO director general Jong Wook Lee declared AIDS a ``global health emergency'' last week and said he would send technical teams to any country that asked for help to fight the incurable disease. In the last 10 days, at least 20 countries - 14 in Africa, three in Latin America and the Caribbean, and three in Asia, including China - have asked for help, Charles Gilks, a WHO medical officer, said Thursday@.

The WHO's proposed pace resembles the agency's all-out efforts last year against the SARS epidemic. Within two weeks, the WHO plans to send out the teams to most of the countries on fact-finding missions. And by Dec. 1, the organization, which has been known for years as a bloated bureaucracy, aims to have its blueprint for treating 3 million people by 2005.

The change at the health organization stems from the election of Lee earlier this year and his selection of top officials, most notably Jim Yong Kim, 43, a Korean-born US resident who cofounded the Cambridge-based Partners in Health, which has done ground-breaking work globally on ensuring basic health care for poor people.

Kim, who is on leave from Harvard University as an assistant professor of medicine and medical anthropology, helped write global protocols for overseeing the treatment of patients with drug-resistant tuberculosis two years ago, and now is the driving force behind the new urgency in AIDS treatment.

Many clinicians, including his peers at Harvard, have argued that more testing needs to be done in order to safeguard against resistances developing with antiretroviral drugs. But Kim said that is not an option.

Some in the human rights community are saying that . . . Africans should be getting the full range of treatment,'' Kim said in a telephone interview from Geneva.But the fact that 6 million people will need treatment but aren't getting it is the most important human rights violation of all. We need to take emergency measures.''

He and others say the task is unmatched in public health, including the eradication of smallpox in the late 1970s.

We've got to build health systems. We've got to train people. We've got to create a health work force,'' Kim said.We think we can do it with simplified training and regimens.''

Bill Foege, one of the leaders of the smallpox eradication effort, said Thursday@ he also sees the job ahead as much more complex than any before it.

This is harder than smallpox,'' said Foege, who is a senior health adviser at the Bill & Melinda Gates Foundation.Smallpox, by and large, did not deal with the intimate parts of life in how it was transmitted. It left a clear trail of where it has been. With AIDS, you don't have that, and there are many attempts by humans to hide the virus.''

Inside WHO, nine task forces are examining different angles of the problem. One group, for example, is talking about how to best enter a community with a treatment plan, which will be necessary to deal with stigma often associated with the disease.

Lee's senior management team also consulted with top leaders fighting the SARS epidemic and those working on polio eradication.

The SARS specialists advised Lee's team to immediately set the guidelines on proper protocols; to be decisive, based on the best available science; and to publicize their efforts to key players around the world through video conferences and the media.

The polio specialists recommended the AIDS team simplify treatment and delivery systems as much as possible, identify community leaders, pay volunteers, and then work out detailed plans on who will do the work in each neighborhood.

As with the SARS effort, WHO will worry about funding the initiative later. Funding for the project would depend on how many countries respond to the WHO plan. WHO officials are also hoping they can tap into the proposed $15 billion that the Bush administration has proposed in the global fight against AIDS.

Despite the WHO's ambitious plan, many AIDS specialists worry that some countries, especially those that have opposed drug treatments for AIDS, will not participate. Officials are also concerned that patients may not respond well to the medicine or show resistance to the antiretroviral drugs or its unchecked side effects, such as liver and kidney failure.

We know that not everybody is going to get Magic Johnson treatment,'' said Malcolm F. McPherson, a professor at Harvard's John F. Kennedy School of Government, referring to the high quality of personal care given to the former National Basketball Association star who announced more than a decade ago he was HIV-positive.But the reason why monitoring is so important is that if you don't watch it carefully, other side effects are going to take hold.''

Kim acknowledged the risk, but he said: ``You have to take chances, instead of debating endlessly. I don't know exactly the way to do it right now, but let's get started, let's figure it out, and let's do it.''


(The Cox web site is at )

c.2003 The Boston Globe

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