摘要：The prospects for antiretroviral therapy in resource-poor settings have changed recently and considerably with the availability of generic drugs, the drastic price reduction of brand-name drugs, and the simplification of treatment. However, such cost reductions, although allowing the implementation of large-scale donor programs, have yet to render treatment accessible and possible in the general population. Successfully providing HIV treatment in high-prevalence/high-caseload countries may require that we redefine the problem as a public health mass therapy program rather than a multiplication of clinical situations. The public health goal cannot simply be the reduction of morbidity and mortality for those treated but must be the reduction in morbidity and mortality for the many, that is, at a population level. THE PROSPECTS FOR antiretroviral (ARV) therapy in Africa and other resource-poor settings have changed so drastically over the last few years that it is almost embarrassing to realize that it could have changed much earlier. Prices of drugs from pharmaceutical giants have fallen 10- to 40-fold, and the emergence of generic drugs as well as the simplification of treatment has made care possible in these countries. 1 However, often overlooked is the fact that such reductions in costs, if they allow the implementation of large-scale donor programs, have yet to render treatment economically accessible to or possible for the general population. Indeed, even with these substantial cost reductions, like those negotiated via the United Nations Global Fund, 2 the US president’s initiative, 3 and the Clinton Foundation, or even the advent of generics, treatment remains beyond the reach of all but the upper classes in numerous countries. 4 It is indeed the paradox of lower ARV therapy costs that these reductions brought with them a cortege of pressures that must be recognized with wide-open eyes. In order for lower ARV therapy costs to truly usher in the era of “global treatment” beyond pilot or research programs, a realistic discussion of attainable goals of ARV treatment in resource-poor countries is necessary. 5 The debate is peculiar in that the necessity of making ARV therapy available in resource-poor countries has been justified for its population benefits (namely, maintenance of economic capacity, distributive justice, and curbing of the HIV epidemic) as much as for the immediate public health goals of reduced morbidity and mortality. As a consequence, these larger population benefits are sometimes seen as primary, with the public health objectives considered a vehicle toward accomplishing these larger goals. But are those goals always in harmony? Or might some of those goals be better attained in other ways? If so, which objectives are the most important? We review the population goals implicit in ARV treatment programs, assess their feasibility, and contrast them with the vehicle that is supposed to bring them to fruition—access to ARV care for the many—before proposing a paradigm shift anchored in today’s reality.
