Unless HIV treatment is properly controlled in developing countries, antiretroviral therapy could become useless due to poor practice in the private sector, according to an editorial in the June 21 edition of the British Medical Journal by Ruairi Brugha, a senior lecturer in public health at the London School of Hygiene and Tropical Medicine.
“Policy makers cannot afford to await conclusive evidence that private providers will soon be at the forefront of providing antiretroviral drugs in developing countries and that their treatment practices will accelerate HIV resistance to those drugs," he wrote. "Private providers are recognised to dominate the market in the treatment of sexually transmitted diseases.”
He notes that most poor people who suspect they have a sexually transmitted infection seek care in the private sector because of the stigma attached to the disease. However, unpublished research carried out by Oxfam in Tanzania showed that this form of health seeking behaviour was further structured by gender and age, with younger women least likely to seek any sort of treatment, older women and younger men likely to consult traditional healers, and older men most likely to go to private practitioners for antibiotics.
There is considerable evidence that private sector prescribing is already a major route to antiretroviral therapy in Africa, and that sub-optimal practice abounds. A study in Zimbabwe carried out in 2000 found that 82% of the pharmacies found to stock HIV drugs carried a single drug, and monotherapy was prescribed to 17% of patients.
Poor prescribing practice driven by the cost of the drugs is likely to continue wherever differential pricing excludes the private sector. Whilst generous discounts for public sector and NGO schemes have been highlighted by Indian generic manufacturers, individuals accessing treatment through private practitioners are continuing to pay much higher prices because the drugs available in pharmacies are either branded products or drugs diverted from the public sector.
Although the author suggests that the main reason for accessing treatment through private practitioners is to avoid the stigma of attending HIV clinics in public hospitals, the uptake of antiretrovirals through private practitioners must also be related to the delays in making treatment available through the public sector. Research from both Uganda and Senegal shows that the major cause of treatment interruption or discontinuation is lack of money.
Donors need to be more active in helping countries to set prescribing and dispensing rules and ensuring compliance with these rules, says Ruairi Bruagh.
Work should start with doctors, nurses and trained pharmacists – governments could use NGOs to monitor private providers, although projects that work with the unorganised individual providers are likely to be highly labour intensive.
National treatment policies need to take account of the coverage achieved by particular types of providers and the population profile they serve. In small towns with large rural catchment areas, private prescribers may be the only medical practitioners available
A guide to working with private sector prescribers is available here
Brugha R et al. Antiretroviral treatment in developing countries: the peril of neglecting private providers. British Medical Journal 326: 1382-4, 2003.