Study examines lessons learned at Africa's first public antiretroviral treatment clinic

Mar 9 2005

A public clinic offering antiretroviral (ARV) treatment to people with HIV/AIDS, recently established in Botswana, has had its share of trials and errors.

However, the obstacles it has encountered--and has largely overcome--can serve as valuable lessons for other developing countries trying to launch their own treatment programs, according to an article in the March 15 issue of Clinical Infectious Diseases, now available online.

According to World Health Organization estimates, only about 700,000 of the 6 million people with HIV/AIDS who need ARV treatment are getting it. Major efforts are underway to increase access to ARV treatment, but many countries are struggling with limited staff and infrastructure.

Botswana's high rates of HIV--more than a third of its population is infected--make it a prime candidate for publicly available ARV treatment. Africa's first public ARV clinic opened in Gaborone, Botswana's capital city, in January of 2002, and was immediately inundated with patients, some of whom had to wait four or five months to begin ARV treatment.

Physical space for consultation and counseling proved to be the first challenge. The facility's 4,000-patient capacity was quickly reached. To handle the influx, additional buildings were erected, and they now accommodate more than 11,000 patients being treated at the clinic.

Clinic staffing changes were also necessary. Initially, medical personnel were rotated in from inpatient hospital wards in order to gain outpatient care experience. However, to ensure consistent care for clinic patients, a core team of HIV specialists was eventually created to staff the clinic and train junior staff as HIV care providers. All ARV clinic staff members involved in patient care received ongoing training to get the most up-to-date information on HIV treatment.

The lack of medical personnel available to staff such a specialized clinic in an African nation has varying causes, depending on the country, according to Richard Marlink, MD, of the Harvard School of Public Health AIDS Initiative and lead author of the article. "In some places, this deficit is not because the experts don't exist, but rather that the system can't pay them or [doesn't] have positions for them," Dr. Marlink said. "In other places, the experts just don't exist in the numbers needed." Botswana has a peculiar combination of the two problems in that there are lots of nursing schools, but no medical schools. Many nurses are often forced to look for work outside Botswana due to a lack of positions that pay well, but physicians have to be contracted from other countries, said Dr. Marlink.

If the country's government institutionalizes the ARV clinic's practice of having specialists train junior staff in HIV treatment, it could help to ensure an ongoing source of expert care providers "so that it's an accepted specialty, as it were, for young nurses and doctors and counselors to enter into a specialized profession of HIV/AIDS care," Dr. Marlink added.

The Botswanan government's ongoing support of efforts to control the spread of HIV/AIDS has been a key to the creation of the ARV clinic. "From President [Ketumile] Masire to President [Festus] Mogae, the leadership on approaching the epidemic as a national epidemic has been unbelievable," Dr. Marlink said.

Most African medical centers deal solely with acute problems, such as medical emergencies, rather than chronic conditions. Therefore, the ARV clinic's successful establishment, as well as its treatment of thousands of HIV-infected people, is promising. "We're hoping that this will help create infrastructure that will help not only with HIV but with other chronic diseases that would normally be easily treated in the West," Dr. Marlink said.