Scaling-Up Highly Active Antiretroviral Therapy (HAART) in Peru: Problems on the Horizon

To the Editor:

The AIDS epidemic has overwhelmed the fragile health system of developing countries. Peru is not the exception to this situation, although the HIV prevalence in the general population is still less than 1%.¹ In May 2004, the National Program, supported by the Ministry of Health and the Global Fund to Fight AIDS, Tuberculosis, and Malaria started to provide highly active antiretroviral therapy (HAART) free of charge.² The National Program operates as a 4-step pyramid: the Ministry of Health on top, the district health authorities and the HIV/AIDS centers at the hospitals in the middle, and the community health centers at the base.

Our hospital cares for 18% of the HIV patients under the National Program, diagnoses 400 new HIV cases, and provides 5000 HIV-related outpatient visits per year. The HIV/AIDS center at our hospital is staffed with 8 physicians. In addition, there are 2 nurses, 1 psychologist, and 1 social worker who are responsible for home visits, psychological evaluation and counseling of candidate patients, data recording, reporting adverse events, and drug dispensing. By June 2006, 716 HIV patients began HAART at our hospital through the National Program. This was achieved due to the extreme dedication of the personnel involved. But currently, our attendance capacity has been surpassed because the staff has remained constant despite the increasing number of patients undergoing follow-up. As a result, the time devoted to patient care has decreased.

The process of drug distribution currently involves many intermediate steps, which are not always successfully coordinated. As a result, there is a significant delay to obtain new drug supplies. Under these conditions, it has not been possible to enroll patients at the expected rate of 50 new patients per month (Fig. 1). In addition, CD4 cell count and viral load measurements are limited, as only 1 central laboratory is in charge of sample taking and processing for all patients from the capital Lima. Only 50% of our patients have viral load and CD4 results.

FIGURE 1: A non-continuous delivery of antiretroviral drugs supply caused a delay in initiation of HAART therapy within the National Program at 2 specific time points: between December 2004-January 2005 and between July 2005-September 2005. The numbers of the y axis represent the absolute number of patients.

These barriers may reduce the efficacy of the program of antiretroviral therapy in our country, a concern that has been expressed also in other countries where HAART was recently introduced.³ Increase in manpower or redistribution of health care personnel from community health centers is necessary to fulfill the increased demand of antiretroviral treatment. A decentralized, single-step drug distribution process, in which each HIV/AIDS treatment center connects directly with the district health authorities could ensure efficient drug supply. Collecting blood samples at peripheral centers and sending them to the central laboratory for processing could assure higher rates of laboratory monitoring.

Juan Echevarría*†

Diego López de Castilla†

Carlos Seas*†

Kristien Verdonck†‡

Eduardo Gotuzzo*†

*Departamento de Enfermedades Infecciosas Tropicales y Dermatológicas, Hospital Nacional Cayetano Heredia, Lima, Perú

†Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Perú

‡HIV and Retrovirology Research Unit, Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium