ootnote'>[56] From a social stance, treatment is believed to reduce stigma and decrease the fear of receiving a positive HIV status. The HIV Equity Initiative in Cange, Haiti has found that even though AIDS is still stigmatized, access to therapy has helped to alleviate stigma.[57] Stigma alleviation is also related to prevention through helping to encourage people to break the silence surrounding the disease and to encourage people to seek testing.

One of the most debated points for and against the provision of treatment is related to the cost of care. As mentioned previously, several scholars argue that HAART is not cost-effective in the developing world, especially when compared to prevention. It should be noted that prevention is almost always cheaper than treatment, regardless of a nations development status. In addition, scholars claim that in order to have cost-effective HIV care, treatment must be involved.[58] The cost of not treating a person with HIV/AIDS includes the following: 1.) Loss of income of adult patients who make-up the work force, 2.) Loss of income of caregivers (parents, children of the elderly), 3.) Loss of patient output, 4.) Funerary expenses, 5.) Orphan care and support, 6.) Death and survivor benefits, 7.) Costs resulting from the breakdown in social cohesion networks, and 8.) Loss of social investments- i.e. education. [59] These expenses, according to Hans Binswanger of the World Bank, far exceed the cost of treatment. Especially considering that the price of treatment has dropped by more than 95% in the last 4 years.

Furthermore, economists are now encouraging nations with a high prevalence of HIV/AIDS to increase spending for HAART. Initially economists estimated that nations who have high HIV infection rates among adults would lose approximately 1% of their Gross National Product (GNP). However, it is now believed that this figure was “grossly underestimated.”[60] Hospitalization costs, the loss of markets, the loss of a trained and educated work force, the costs for orphan care, etc. have had a negative financial impact beyond initial expectations. For example, if South Africa continues to suffer from extremely high HIV prevalence rates, then the World Bank estimates that within four generations their economy will be halved. Advocates argue that treatment will have a positive effect on national development as well.[61] Thus, economists argue that it is crucial for countries with high HIV prevalence rates to scale-up provision and distribution of generic drugs.

This debate will continue to be waged and issues regarding treatment, prevention, cost, resistance, and adherence will remain important considerations central to HAART provision in resource-limited settings.


Success Stories:

            The following examples are brief case studies where resource-limited nations have been successful in their provision and distribution of HAART. They also represent models of care, which are currently being expanded and utilized in other parts of the world.



Brazil’s response to the AIDS pandemic, especially their provision of free ARV treatment, developed out of governmental efforts, community initiative, and advocacy. Nearly 105,000 of Brazil’s estimated 600,000 HIV/AIDS patients receive free ARV treatment. Brazil has been able to avert 90,000 deaths, prevent 60,000 new cases, and 358,000 AIDS-related hospitalizations between 1996 and 2002.[62] Brazil has also managed to reduce mother-to-child HIV transmission rates from 30% to 0.02%. As of 2003, Brazil had saved more than $2 billion dollars as a result of its HIV/AIDS program. The annual STD/AIDS program is approximately US$500 million, with 60% spent on medication. Overall, Brazil’s achievement is a direct result of the holistic and national response directly tied to public health efforts and their development of locally made generic low-priced drugs.[63]



Haiti is one of the poorest countries in the western hemisphere and is ranked among the poorest nations in the world. The country’s GNP is approximately US$400 and unemployment rates exceed 70%.[64] Considering HIV/AIDS is now seen as disease associated with poverty, it is not surprising that Haiti has one of the highest HIV prevalence rates in the western hemisphere. According to UNAIDS, Haiti’s national HIV prevalence rate is between five and six percent.[65] Complicating the relationship between poverty and HIV/AIDS is a weak national public infrastructure and a meager health budget of less than US$2 per person, per year.[66] Despite high HIV prevalence, impoverished living conditions, and insufficient health care, successful implementation and monitoring of highly active antiretroviral therapy (HAART) has been achieved in the rural area of Haiti, known as Cange. A community-based approach designed to provide directly-observed therapy with highly-active antiretroviral therapy (DOT-HAART) to patients with advanced HIV was developed and implemented in Cange in 1998.[67] This model was based upon the success of directly-observed therapy for tuberculosis. HIV patients were assigned to work with a community health worker who, “observes ingestion of pills; responds to patient and family concerns; and offers moral support”[68]. Social support was also offered in conjunction with personal observation and aid of medication by hosting monthly meetings for patients, offering economic assistance, and other social services. This approach was extremely successful and achieved nearly full coverage within the area of Cange. Furthermore, this community-based initiative, which currently treats approximately 100 patients, has high rates of patient compliance and managed to reduce opportunistic infections, hospital admissions as well as patient mortality.[69] In addition to these successes, patients rarely experienced side effects and very few patients have had to change treatment regimens.[70] Based on the success of the community-based initiative in Cange, DOT-HAART treatment has been scaled-up and should cover central Haiti and Port au Prince by the year 2008.[71]


Conclusion: Antiretroviral Therapy- Considerations for the future

            This chapter has examined various issues regarding antiretroviral treatment in the developing world, including international trade and patent laws, use of generic drugs, and arguments regarding drug resistance, patient adherence, cost-effectiveness, and prevention. Ultimately these concerns and the root of the issue surrounding HIV/AIDS treatment must consider the best quality of care for the millions of people currently living with HIV/AIDS and how best to prevent future infections. The future must continue to advocate for antiretroviral therapy in resource-limited settings and aim to find cost-effective, innovative ways to make HAART treatment a major part of international and national AIDS efforts. We must also look at effective preventive medical interventions (including vaccines and microbicides) and continue aggressively pushing prevention programs. Also the global community must address issues of growing poverty, political instability, and equity. Responses to these issues should be considered within a human rights framework.

            Finally, it is important to mention that issues regarding antiretroviral therapy in the developing world are consistently changing—changes in policies surrounding ARVs, trade and patent laws, developments in cost-effective care, etc. are emerging almost daily. Moreover, much of the information a year ago is now out-dated due to vast and swift changes within the field. Thus, the following websites are interesting resources to gain up-to-date information about new developments surrounding antiretroviral treatment in the developing world.



AIDS Related Information Sources:


Accelerating Access Initiative



Debt, AIDS, Trade, Africa



Doctors Without Borders: Access to Essential Medicines




The Global Fund






World Health Organization Three by Five Initiative



News Sources

The New York Times Online



BBC News AIDS Page



The Lancet






[1] WHO and UNAIDS (2003). Treating 3 Million by 2005: Making it happen, WHO

UNAIDS. 2003.

[2] Essex, M. and S. Mboup (2002). Introduction: The Etiology of AIDS. AIDS in Africa Second Edition. M. Essex, S. Mboup, P. J. Kanki, R. G. Marlink and S. D. Tlou. New York, Kluwer Academic/ Plenum Publishers: 1-10.

[3] HIV is a retrovirus characterized by a latency period prior to attacking an individual’s immune cells and antibodies. See footnote 1.

[4] UNAIDS (2003). AIDS epidemic update. Geneva, UNAIDS, WHO: 1-39, UNFPA (2003). State of World Population 2003 Making 1 billion count: Investing in adolescents' health and rights. Geneva, United Nations Population Fund: 92.

[5] UNICEF, UNAIDS, et al. (2002). Young People and HIV/AIDS Opportunity in Crisis. Geneva, UNICEF, UNAIDS, WHO: 1-48, OXFAM and IYP (2003). Highly Affected, Rarely Considered: The International Youth Parliament Commission's Report on the Impacts of Globalization on Young People. Sydney, International Youth Parliament and OXFAM: 169.

-UNAIDS (2003). See footnote 2.

[6] DATA (2004). Facts About... Debt, AIDS, Trade, Africa. 2004. http://www.data.org

-UNAIDS (2003). See footnote 2.

[7] UNAIDS (2002). Epidemiological Fact Sheets on HIV/AIDS and Sexually Transmitted Infections: Kenya, UNAIDS: 1-14.

[8] Weidle, P. J., T. D. Mastro, et al. (2002). "HIV/AIDS treatment and HIV vaccines for Africa." The Lancet 359: 2261-2267.

[9] MSF (2004). HIV/AIDS, Medecins Sans Frontieres. 2004.

[10] Even though ART and HAART are defined by triple therapy recent publications primarily specify triple-drug combinations as HAART. Based on current usage this chapter will also refer to HAART.

[11] Amoroso, A., C. E. Davis, et al. (2002). Antiretroviral Therapy in Resource-Limited Settings. AIDS in Africa Second Edition. M. Essex, S. Mboup, P. J. Kanki, R. G. Marlink and S. D. Tlou. New York, Kluwer Academic/ Plenum Publishers: 322-344.

[12] Amoroso et al. (2002). See footnote 2.

[13] Amoroso et al. (2002). See footnote 2.

[14] IRIN (2003). Global: WHO announces approval of generic antiretrovirals, UN Office for the Coordination of Humanitarian Affairs. 2004. http://www.irinnews.org/report.asp?ReportID=38166&SelectRegion=Global

[15] MSF (2004). 2 Pills a day saving lives, Medecins Sans Frontieres. 2004.

[16] IRIN (2003). See footnote 5

[17] Treatment Action Campaign is a South African grassroots organization, whose objectives are to “1. Ensure access to affordable and quality treatment for people with HIV/AIDS. 2. Prevent and eliminate new HIV infections. 3. Improve the affordability and quality of health-care access for all.” More information about this organization can be found at: http://www.tac.org.za/

[18] Doctors Without Borders launched a campaign advocating for access to essential treatments worldwide. More on this campaign and related information regarding AIDS drug treatments, as well as images of interesting educational posters, can be found at: http://www.accessmed-msf.org/index.asp

[19] Doctors Without Borders (2003). Trading Away Health. New York, Doctors Without Borders: 1-12.

[20] Gunaratnam, P. (2003). HIV/AIDS Prevention, Treatment and Care For Yougn People. In Highly Affected, Rarely Considered: The International Youth Parliament Commission's Report on the Impacts of Globalization on Young People. Sydney, OXFAM

International Youth Parliament: 45-57.

[21] Vaz, M. (2003). "Brazil offers expertise and support to Africa." The Lancet 362: 215.

[22] It is important to note that Cipla has been one of the driving forces behind the decline of ARV prices.

[23] Sharma, D. C. (2003). "ARV prices nosedive after Clinton brokering." The Lancet 362: 1467.

[24] Amoroso et al. (2002). See footnote 2.

-Marseille, E., P. B. Hoffmann, et al. (2002). "HIV Prevention before HAART in sub-Saharan Africa." Ibid. 359: 1851-1856.

-Weidle, P. J., T. D. Mastro, et al. (2002). "HIV/AIDS treatment and HIV vaccines for Africa." The Lancet 359: 2261-2267.

[25] Taegtmeyer, M. and K. Chebet (2002). "Overcoming challenges to the implementation of antiretroviral therapy in Kenya." The Lancet Infectious Diseases 2: 51-53, Liechty, C. A. and D. R. Bangsberg (2003). "Doubts about DOT: antiretroviral therapy for resource-poor countries." AIDS 17(9): 1383-1387.

[26] Hanson, S. (2002). "AIDS control in sub-Saharan Africa-- are more drugs and money the solution?" The Lancet Infectious Diseases 2: 71-72.

-Marseille, E. et al. (2002). See footnote 8.

[27] Pill burden refers to the number of pills patients are required to take. Considering ART or triple therapy requires taking three pills multiple times a day it is reported that patients may not stick to the treatment due to the burden of taking multiple medications, multiple times a day.

[28] Binswanger, H. P. (2003). "Willingness to pay for AIDS treatment: myths and realities." The Lancet 362: 1152-1153. pg. 1153

[29] Liechty, C. et al. (2002). See footnote 9. pg. 1384.

[30] Taegtmeyer and Chebet (2002). See footnote 9.

-Amoroso et al. (2002). See footnote 2.

[31] Weidle, P.J. et al. (2002), See footnote 8.

[32] Amoroso et al. (2002) See footnote 2.

[33] Hanson, S. (2002). See footnote 10. pg. 71.

[34] Kallings, L. O. and S. Vella (2001). "Access to HIV/AIDS Care and Treatment in the South of the World." AIDS 15(7): IAS1-IAS3.

[35] Creese, A., K. Floyd, et al. (2002). "Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence." The Lancet 359: 1635-1642.

-Marseille, E. et al. (2002). See footnote 8.

-Lush, L. (2002). The International Effort for Anti-Retrovirals: Politics or Public Health? The Economics of Essential Medicines. B. Granville. London, Royal Institute of International Affairs: 232-241.

[36] Marseille, E. et al. (2002) pg. 1853.

[37] Lush, L. (2002). See footnote 19. pg. 238

[38] Lush, L. (2002). Pg. 240

[39] Liechty, C. et al. (2002). See footnote 9.

[40] Marseille, E. et al. (2002). See footnote 8.

-Weidle, P.J. et al. (2002). See footnote 8.

[41] Marseille, E. et al. (2002)

[42] Marseille, E. et al. (2002). Pg. 1855

[43] Marseille, E. et. al. (2002). Pg. 1855

[44] Farmer, P., F. Leandre, et al. (2001). "Community-base approaches to HIV treatment in resource-poor settings." The Lancet 358: 404-409, Laurent, C., N. Diakhate, et al. (2002). "The Senegalese government's highly active antiretroviral therapy initiative: an 18 month follow-up study." AIDS 16(10): 1363-1370, Weidle, P. J., S. Malamba, et al. (2002). "Assessment of a pilot antiretroviral drug therapy programme in Uganda: patients' responses, survival, and drug resistance." The Lancet 360: July 6.

[45] Laurent, C. et al. (2002). See footnote 26.

[46] Laurent, C. et al. (2002). Pg. 1369.

[47] Weidle, P. J. et al. (2002b). See footnote 26.

[48] Liechty, C. et al. (2002). See footnote 9.

[49] McNeil, D. G. (2003). Africans Outdo U.S. Patients in Following AIDS Therapy. The New York Times. New York.

[50] Liechty, C. et al. (2002). See footnote 9.

[51] Liechty, C. et al. (2002)

[52] Farmer et al. (2001).

[53] Ashraf, H. (2003). "Economists tell scientists AIDS drug projects can be scaled up." The Lancet 362: 215. pg. 215

[54] Farmer, P., F. Leandre, et al. (2001). "Community-base approaches to HIV treatment in resource-poor settings." Ibid. 358: 404-409. See footnote 26. pg. 407.

[55] Piot, P., D. Zewdie, et al. (2002). "Correspondence: HIV/AIDS prevention and treatment." Ibid. 360: 86.

[56] Liechty, C. et al. (2002). See footnote 9.

-Farmer, P. et al. (2001). See footnote 36.

[57] Farmer et al. (2001).

[58] Piot, P. et al. (2002).

[59] Binswanger, H. P. (2003). "Willingness to pay for AIDS treatment: myths and realities." The Lancet 362: 1152-1153.

[60] Ashraf, H. (2003). Pg. 215

[61] Ashraf, H. (2003).

[62] Doctors Without Borders. (2003).

[63] Galvao, Jane. 2004. Access to antiretrovirals: where South Africa, China, and Brazil meet. The Lancet. 363: 493

[64] Farmer et al. (2001)

[65] UNAIDS (2003).

[66] Mukherjee, J. S. (2003). "HIV-1 care in resource-poor settings: a view from Haiti." The Lancet 362(9388): 994-995.

[67] Farmer et al. (2001)

[68] Farmer et al. (2001) pg. 405

[69] At the time the article by Nierengarten was published in 2003, patient mortality had been reduced to 0%. You can learn more about this community-based initiative by visiting the Partners in Health website at http://www.pih.org.

[70] Farmer et al. (2001)

-Nierengarten, M.-B. (2003). "Haiti's HIV equity initiative." The Lancet Infectious Diseases.

[71] Mukherjee, J. S. (2003). "HIV-1 care in resource-poor settings: a view from Haiti." The Lancet 362(9388): 994-995.