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Lessons From Africa

Rabkin, Miriam MD, MPH*†‡; El-Sadr, Wafaa M MD, MPH*†‡; Mugyenyi, Peter MB, ChB, FRCPI, FRCPEdin§; Ramatlapeng, Mphu K MD‖; De Cock, Kevin M MD, FRCP(UK), DTM&H¶

JAIDS Journal of Acquired Immune Deficiency Syndromes: 15 December 2010 - Volume 55 - Issue - pp S141-S143
doi: 10.1097/QAI.0b013e3181fbcb76
Supplement Article

Delayed access to HIV care and treatment in sub-Saharan Africa meant that the early years of HIV scale-up were characterized by a largely North-to-South transfer of knowledge and resources. Clinicians from wealthy countries were among the first to gain experience with antiretroviral treatment and care of people living with HIV and shared key lessons with their colleagues in sub-Saharan Africa. Ten years later, lessons from Africa learned from the remarkable achievements of HIV programs now have the potential to inform the response to the US domestic epidemic.

From the *International Center for AIDS Care and Treatment Programs, Columbia University Mailman School of Public Health, New York, NY; †Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY; ‡Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY; §Joint Clinical Research Center, Kampala, Uganda; ∥Lesotho Ministry of Health and Social Welfare, Maseru, Lesotho; and ¶U.S. Centers for Disease Control and Prevention, Atlanta, GA.

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of either the US Centers for Disease Control or the Lesotho Ministry of Health and Social Welfare, Maserv, Lesotho.

The authors have no funding or conflicts of interest to disclose.

Correspondence to: Wafaa M. El-Sadr, MD, MPH, International Center for AIDS Care and Treatment Programs, 722 West 168th Street, Room 715, New York, NY 10032 (e-mail:

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The global response to the HIV epidemic has often been perceived as a North-to-South transfer of expertise, as well as resources. Because HIV care and treatment, including antiretroviral therapy (ART), were first widely available in wealthy countries, practitioners from the United States, western Europe, and similarly well-resourced settings were among the first to gain experience treating people living with HIV (PLWH), the first to develop clinical guidelines, and the first to design and implement HIV service delivery programs. The delayed initiation of HIV care and treatment programs in sub-Saharan Africa created a “lost decade,” in which millions of PLWH were deprived of life-saving interventions and only a few African clinicians gained experience with HIV care and treatment. When resources finally became available, key insights from years of experience in the North informed the scale-up in the South. Examples include the importance of combination ART and the perils of sequential monotherapy, the critical role of retention in care and adherence to treatment, the need for multidisciplinary teams of providers, and the key role for PLWH in shaping the response to the HIV epidemic. These principles are now accepted as fundamental to effective HIV programs.

Times have changed, however, and the flow of information and experience is no longer a one-way street. Clinicians and public health practitioners in many lower-income countries have rapidly acquired proficiency in the prevention, care, and treatment of HIV and now lead the development and implementation of their national guidelines and trainings. The response to the African HIV epidemic has provided successful models of rapid program scale-up and highlighted the fact that global health requires global financing. Fiscal sustainability is unlikely to be achieved in the near future, but technical sustainability is much more promising. Although funds and technical assistance from the global North are still welcome and necessary in many settings, local solutions and expertise often provide the most effective interventions. This new equilibrium highlights the fact that innovations and best practices are generated worldwide-and that South-South and South-North transfers and technical assistance have important roles to play. Indeed, despite marked differences in the magnitude and characteristics of the HIV epidemics in the United States and in sub-Saharan Africa, the response to the US HIV epidemic may be enhanced by some of the lessons learned from the enormous success of HIV program scale-up in Africa.

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Sub-Saharan Africa has a generalized HIV epidemic with high seroprevalence rates in many countries, although recent data indicate that specific subpopulations are more severely impacted. For example, young women in southern Africa are at particular risk for HIV infection when contrasted with young men of the same age, and there are high rates of HIV infection among drug users and men who have sex with men in some countries.1 In contrast, the overall HIV prevalence in the United States is much lower, and the US epidemic is a localized one, with foci of high prevalence rivaling that in some parts of sub-Saharan Africa, particularly among men who have sex with men and African Americans.2

Another contrast is the state of health systems in the United States compared with those in sub-Saharan Africa. In 2007, per capita total expenditure on health was $7285 in the United States, compared with $819 in South Africa, $79 in Zambia, and $39 in Mozambique.3 Out-of-pocket expenditures represent 12% of the total health expenditures in the United States, compared with 33% in the African region as a whole.4 There is a glaring difference in the availability of health workers, with approximately 27 physicians and 560 health workers per 10,000 inhabitants in the United States compared with 2 and 23 per 10,000 inhabitants in the African region.3,4 The United States has 31 hospital beds per 10,000 people, compared with 1.8 in Ethiopia, 4 in Côte d'Ivoire, and 13 in Lesotho.5 In 2007, healthy life expectancy at birth was 70 years in the United States and 45 years in the African region.3 Although precise data are lacking, PLWH in the United States have far greater access to HIV care and treatment than those in Africa. However, the US response to the HIV epidemic has not been without its challenges, including continued HIV transmission and disparities in access to HIV services.6

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The response to HIV in Africa is as diverse and heterogeneous as the epidemic itself, with important within-country and between-country differences. Although generalizations about the 47 different countries in sub-Saharan Africa are not always helpful, several recurrent lessons have emerged. We note that these innovations are not limited to the African region and that additional important lessons are available from around the world.

* National plans: Since 2004, the UNAIDS has emphasized the importance of the “Three Ones”: a single national AIDS coordinating authority, a single national HIV/AIDS action framework, and a single national monitoring and evaluation system for HIV programs.7 Countries such as Kenya and Ethiopia have had national plans for years, with targets and budgets supporting concrete objectives and activities. Although clinical guidelines have been available for many years, the United States released its first-ever National HIV/AIDS Strategic Plan in 2010.6

* Targets and accountability: The United States can learn from many African countries that have developed specific numeric targets for HIV testing, care, and treatment based on the best available information about the local prevalence and need. Enrollment and coverage targets have been developed for the site, district, province, and national levels, and the progress against targets is reported and shared. In Ethiopia, for example, the Federal Ministry of Health and the Federal HIV/AIDS Prevention and Control Office publish monthly data on the enrollment in HIV care and ART for each region, and for every health care facility providing HIV services in the country. ART coverage is an indicator in WHO's World Health Statistics report, which publishes annual estimates of national ART coverage among people with advanced HIV infection and prevention of mother-to-child transmission coverage among HIV-infected pregnant women in more than 100 countries; these data are difficult to ascertain for the United States.

* Algorithmic guidelines: The development of simple algorithmic HIV treatment guidelines in response to physician shortages has enabled not only rapid scale-up of HIV services but also the standardization of first- and second-line treatment, streamlined drug procurement, and task shifting from physicians to nurses and other health workers. In many settings, these guidelines have also averted the “pharmacologic chaos” seen in some resource-rich settings, in which personalized prescribing and disregard of guidelines can devolve into unnecessarily complex care, over-use of laboratory investigations, and even reported misuse of ART.8

* Know your epidemic: With the exception of data from the National Health and Nutrition Examination Survey, the United States lacks the detailed information found in Demographic Health Surveys, Multiple Indicator Cluster Surveys, antenatal sentinel surveillance, and initiatives such as the 2007 Kenya AIDS Indicator Survey, which provides a detailed and profoundly useful snapshot of the epidemic in that country.9 On the other hand, national disease surveillance systems (especially those based on case reporting) are typically much more robust in resource-rich settings like the United States.

* Task shifting: Driven by a critical shortage of physicians and nurses,10,11 the HIV response in sub-Saharan Africa has been characterized by health workforce innovations, task shifting, and task sharing.12,13 For example, in some countries, nurses and clinical officers can now prescribe and/or refill antiretroviral medications,14,15 whereas in the United States, these activities are limited to physicians and nurse practitioners. Similar vision and creativity about professional roles and responsibilities may help the United States face one of its key challenges-substantially expanding and improving HIV screening and testing programs, identifying the estimated 250,000 undiagnosed HIV-infected individuals, and linking them to care and treatment services and providing services to an increased number of newly identified PLWHs. In addition, addressing the disparities in access to services for PLWHs as priorities in the national HIV strategy will require availability of ever increasing numbers of providers.6

* Diagnostics and case finding: Although countries in sub-Saharan Africa have a long way to go in achieving broad access to HIV testing for their populations, these same countries were quick to adopt rapid HIV testing assays, utilizing algorithms that do not include Western blot assays. They also pioneered the provision of such testing by lay workers trained to perform rapid HIV tests in mobile, community, and even home-based settings. At health facilities, provider initiated point-of-service screening for HIV enables rapid testing at multiple venues, from antenatal care, to tuberculosis (TB) clinics, to outpatient departments.

* Integration of services: Although access to integrated service delivery varies from site to site and country to country, some types of integrated services are often more developed and more accessible in African programs than in the United States. The integration of HIV and TB services, including TB screening for patients with HIV and HIV testing for patients with TB, is one example; the use of antenatal care programs for the provision of prevention of mother-to-child transmission and the identification and enrollment of women and families with HIV into HIV services is another.

* Research: Studies conducted in sub-Saharan Africa have contributed substantially to the world's knowledge base on HIV/AIDS, directly influencing practice elsewhere. After years of productive research in descriptive and analytic epidemiology focusing on natural history, risk factors and disease associations,16 Africa is now a vibrant setting for clinical trials of relevance worldwide, in areas such as prevention and treatment of HIV-associated tuberculosis, HIV prevention, microbicides, and other interventions.17-19

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Despite the horrific impact of the HIV epidemic, it has also triggered an outpouring of solidarity within and between nations. Again and again, we see the impact of generous support from individuals, communities, and countries. Although common wisdom suggests that financial and technical inputs from resource-rich settings can and should continue to inform the design and implementation of HIV programs in the global South when appropriate, the potential benefits of South-South and South-North contributions should also be acknowledged. Remarkable innovations have germinated in Africa in the process of scaling up HIV prevention, care, and treatment programs; many of these can inform the response to the HIV epidemic. As the United States continues its quest to control the epidemic in its midst, we should pause and consider what we can learn from Africa.

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The authors acknowledge their valued colleagues in the United States and in Africa who have contributed so much to the response to the HIV epidemic, as well as the patients and families who have trusted us with their care. They also acknowledge contributions by Shannon Hader and Chris Collins.

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HIV scale-up; program implementation; lessons; Africa

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