Thursday 7 August 2008

Starting is the hardest part

When to start antiretroviral therapy (ART)? This controversy dates back to David Ho's "hit early, hit hard" campaign soon after ART was first introduced in 1996. This was replaced by a very conservative approach, which basically said "wait until people are sick."

Now the various AIDS societies and government bodies in the West seem to be vying with each other to see how fast they can ease the starting criteria. (It's difficult to find the right words; they are lowering the threshold by raising the CD4 count at which ART should be started).

But the fact is that, even if the WHO - and the Indonesian Ministry of Health - move in the same direction, most people starting ART here will not be affected. Why? Because most continue to be diagnosed with HIV only after they fall sick with a serious opportunistic infection. They would meet almost any criteria for starting ART.

But this is not the only barrier. Even those who are aware of their infection earlier are often reluctant to start. They may be worried about side effects, or about sustainability of supplies of drugs, or continued commitment by the government to provide the treatment free-of-charge. But I think we often underestimate the mental block: starting ART is an admission of failure.

An admission that the virus is getting the better of us (we've been persuading ourselves that healthy living - or perhaps jamu - is going to keep it at bay); an acceptance that our lives are going to be controlled by our drugs (never leave home without them); and an acknowledgement that twice a day when we take our drugs, we'll be reminded that we're living with the virus (we've probably been trying to forget this for the last few years).

We're all great procrastinators, and we all hate to fail. This is another time when it's easy to delay a decision.

Babé

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