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Introducing ARVs in Resource-poor Settings : Expected and Unexpected Challenges and Consequences

Twenty years after the discovery of HIV, AIDS has become the world’s leading infectious cause of adult death. In most industrialized countries, AIDS mortality has plunged sharply with the advent of antiretroviral therapy. The vast majority of those infected, however, do not have access to modern HIV care, and some experts have argued that introducing such therapy is not a ranking priority. This paper presents the experience of an integrated HIV prevention and care project in rural Haiti in order to explore the challenges to national AIDS programs and other bodies in the “least developed” countries as more resources are made available for HIV prevention and care. The Haiti experience suggests that improving clinical services can improve the quality of prevention efforts, boost staff morale, and reduce AIDS-related stigma. Other lessons learned during the first few years of one of the few donor-supported treatment projects in a very poor country suggest that the full participation of community health workers will be required if HIV prevention and care are to reach the poorest and most vulnerable communities; adjuvant social services must also be part of a good project, as must attention to tuberculosis and other primary health care needs. It is concluded that only a “biosocial framework” drawing on both qualitative and quantitative