Scaling up antiretroviral treatment in resource-poor settings.

Anthony Harries and colleagues (June 3, p 1870) do well to explore the tensions between technical and public-health approaches to the HIV/ AIDS epidemic in Malawi. However, they miss opportunities to discuss several fundamental issues. Important lessons could be learned from neighbouring countries. In Mozambique, the antiretroviral treatment (ART) scale-up programme is very similar to that of Malawi, using HIV day hospitals as the focus of care for HIV-positive people. However, these specialised treatment centres for HIV/AIDS have created problems of two-way discrimination. On the one hand, many HIV-infected patients are reluctant to approach the HIV services for fear of discrimination. But on the other hand, patients who are not HIVpositive are silently denied adequate general medical care as resources become diverted towards HIV-related illnesses. In a country where 10% or more of the population are infected with HIV, real scale-up will occur not by simplifying procedures as Harries and colleagues propose, but by tackling the fundamental problem of vertical programmes. Shouldn’t we be discussing decentralised testing, counselling, and care in peripheral health centres and health posts, where HIV services can be totally integrated into the primary health-care service and as a result begin to overcome the twoway discrimination that is inevitable in vertical ART programmes?