Scale up and follow up: the struggle to stay on AIDS treatment in Africa

Not so long ago, the number of HIV-positive persons in Africa who had access to antiretroviral drugs was painfully low. Through important initiatives such as the US President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, millions have been put on AIDS treatment in the past few years. Available graphs on treatment access show a healthy upward trajectory, flatter in some parts of the developing world, and steeper in others, but nevertheless going up. And up is good.

A recent report in the New York Times shows another side of the story. Getting people started on antiretroviral drugs is one thing, keeping them on the treatment is another. HIV treatment, as it currently stands, is lifelong. Once you start, there is no stopping: or rather, there is stopping, but with disasterous consequences for the health of individuals and potentially for the community (if expensive to treat resistant strains of HIV thereby emerge). But keeping people -- increasingly vast numbers of them -- from defaulting on their treatment is a tremendous challenge with many obstacles. It is hard to know how many are 'lost to follow up', but if it is as the report states (between 15-40%), then we are talking about millions.

The agencies that are to be praised for efforts to increase treatment access may also shoulder some of the blame for the current situation. For years, 'numbers of persons on treatment' were the stuff of progress reports, the ultimate marker of program success, and where efforts and funding were to be largely concentrated. The focus was not on keeping people on their treatment regimes. If hell is not to be paved with good intentions, attention is going to have to subtly shift, the causes of loss to follow-up will have to be thoroughly explored, and support will have to provide to those tracing treatment defaulters and coaxing them to take their drugs.