Building Medical Infrastructure to Treat HIV/AIDS in Developing Countries: Laying the Groundwork for the Delivery of ARVs

Renè Durazzo, Pangaea’s Director of Global Programs, has a short answer when asked what it is that Pangaea does in the fight against HIV/AIDS: “We help set up medical systems that will get people drugs.” This simple statement points to a complex set of issues that must be addressed before life-saving antiretroviral drugs (ARVs) can be provided to an individual who needs them in sub-Saharan Africa or elsewhere in the developing world.

According to Renè, “There’s been a lot of talk in the press about how ‘lack of infrastructure’ is preventing the fast scale-up of ARV treatment programs for people with HIV/AIDS in Africa. For Pangaea, building ‘infrastructure,’ in part means laying down a planning path for a national government or local medical facility that will utlimately lead to the same basic outcome — a clinic opening its doors to provide quality care and treatment to AIDS patients.” One of Pangaea’s primary roles is to provide planning and project management support to local doctors, healthcare administrators, and government officials who have been charged with developing HIV/AIDS care and treatment programs that include access to HIV antiretroviral (ARV) drugs. How does one start to develop such a program in an African country where resources are limited and trained personnel are in scarce supply?

Pangaea has worked on HIV treatment and care start up projects on both a community level and at a countrywide level. Interestingly, both levels require a similar development path.

One case in point is St. Mary’s Hospital, which sits just outside of Durban in KwaZulu-Natal, South Africa. Working in partnership with the AIDS Research Center at Massachusetts General Hospital, Pangaea personnel worked with the staff of St. Mary’s from April 2002 to March 2003 to assist in the creation of a new HIV/AIDS clinic that would provide ARV treatment and care. At the time the project started, St. Mary’s hospital itself was full of AIDS patients, often in the final stages of the disease, but the facility lacked a special unit to specifically handle HIV/AIDS. After making the decision to form the clinic, a working group of St. Mary’s doctors, administrators and other support personnel was formed to map out how the new clinic, Ithemba, would be organized and brought on line. This mapping process was key to the future success of the project. It involved thinking through and answering with great specificity fundamental questions about the “vision” for the clinic operation. The basic questions included:

• What range of care and treatment services will be provided?
• How many patients will be treated?
• Who will deliver these services?
• How will these services be delivered?
• What systems will have to be in place before the first patient is seen?
• What systems are already in place?
• Where are the gaps?
• What new systems will have to be created?
• What are all the financial costs?
• What will the management structure look like?
• What are the key staff positions and skill sets needed to operate effectively?

Renè describes such a planning process in this way: “You start by imagining the first patient walking through the door and then develop a detailed, step-by-step map of everything that will have to be in place to treat that patient from intake to discharge. It’s an incredibly focused, labor-intensive process, but the initiative’s success is greatly determine by how well you deal with the detail up front.” At St. Mary’s, the five-month planning process concluded in September of 2002 and the clinic opened its doors in March of 2003. In its first year, Ithemba provided ARV treatment to 100 patients and is in planning more expansion in the months to come.

In contrast to St. Mary’s, Pangaea has also applied its infrastructure mapping tools to the development of national ARV treatment and care plans in South Africa and Rwanda. “Its been our experience that relatively the same questions have to be answered and mapped whether you want to build ARV treatment capacity for a medical facility or for a country,” observed Pangaea’s global program director. “What is essential is that you do the question mapping and planning with great discipline and specificity at the beginning of the process.”

Certainly the infrastructure planning challenges become increasingly complex in moving from a local to a national scale of effort. However, the infrastructure goal remains the same — ensuring that a person living with HIV can walk into a nearby clinic to receive life-sustaining treatment and care. “That is the goal whether the project is scaled for 35 patients or 5 million,” said Durazzo.