The road towards universal access to antiretroviral treatment is now more easily viable since the WHO changed the eligibility criteria for this treatment, especially for HIV-positive pregnant women.
However, the new problem that emerged from the scientific world is how to retain patients in treatment programs that last a lifetime. The treatment for HIV / AIDS is in fact a treatment that can never be interrupted, so not to allow the virus to regain the upper hand. This adherence to the treatment program is called retention in care. In a recent report, the WHO defines retention as a complete package including preventive services, treatment and support that keep the patient connected successfully to care programs, since the test for HIV through the eligibility to treatment up to administration in the life of antiretroviral therapy. Retention is the key to reduce mortality and morbidity related to HIV, to reduce the incidence of new infections among adults and among children and to reduce the development of resistance to therapy. The period from diagnosis to beginning of treatment appears particularly delicate, when losses of patients are greater.
In countries with limited resources, there are several factors that affect retention: the health status of the patient, poverty, distance from the center of care, the cost of transport, knowledge of their disease and of possible adverse reactions as a result of taking the therapy, the doctor-patient relationship, the waiting time at the center of care, malnutrition, stigma and discrimination.
From the "Maputo Initiative", in the agreement reached by the DREAM program and the African Ministries who participated in the workshop which was held in Maputo in March 2013, there were some points that could favor the retention in these countries: free services, a safe supply chain of antiretroviral drugs, decentralization and integration of services, early detection and prenatal assessment of nutritional status with nutritional support.
However, one point among others is particularly important, namely the community support for continued adherence to treatment programs, in particular those of EMTCT (Elimination Mother To Child Transmission). The community health workers trained for this purpose are a powerful tool to increase rates of retention and adherence. At the side event organized in Geneva on the occasion of the 66th World Health Assembly, DREAM was able to demonstrate how the intervention program has led to a success that is not based only on the administration of therapies, but also on building a comprehensive model of care. This requires a strong community approach and the presence of social capital of high quality. The need to create a network around the patient, not only made of services but also and especially of people. It seems this is the key to facilitate the retention in all its delicate steps, starting from enrollment of the patient to the treatment program. In the DREAM program the health and community workers have had a fundamental role from the very beginning. These patients who started treatment and immediately felt the benefit given by the therapy, decided to become ambassadors of the program. In fact, thanks to their personal experience and the training received, they are the best witnesses of the effectiveness of care, able to encourage the uncertain, support the sick, teach the best practices for the prevention of infections, the importance of hygiene and rules of proper nutrition, especially for children. These witnesses have been in time one of the key points for the success of the treatment, allowing to obtain a good retention through health and nutrition education, lessons that take place in the health center, home care that allow a complete and continued care for the sickest patients, the promotion of public meetings at various levels. Health education, standards of hygiene that spread widely among the people in the villages and suburban areas, often among the poorest, have a great impact which results in the reduction of mortality rates in Africa caused by disorders related to AIDS but also from malnutrition, malarias and other diseases related to poor hygiene and ignorance.
The work of these testimonials is further reinforced by their training and continuous updates made through training courses in which the DREAM program has decided to invest since the early years.
Since its birth, DREAM has organized 24 training courses in the countries where it operates, forming more than 5,000 African professionals.
The DREAM Program and Project Malawi in recent years have decided to concentrate their efforts promoting numerous training courses for "Community Health Workers." Even in this small country, after that DREAM has paved the way for universal access to antiretroviral therapy, the challenge today is that of adherence to the care and maintenance in life of the patients under treatment.
The Community Health Workers can make the difference: in DREAM centers, where they are present, the number of lost to follow-up is negligible. Their work forms a bridge between the centers of excellence and patients scattered in suburban and rural areas of Africa. Many institutions in the country have become aware of the importance of these new professionals for the success of programs that fight HIV, so several patient associations have asked to participate to the courses and in the last months numerous members of some of the associations of people with HIV (amongst which: MANERELA: Malawi Network of Religious Leaders Living with or Affected by HIV and AIDS, COWLHA: Coalition of Women Living with HIV and AIDS, NAPHAM: National Association for People Living with HIV and AIDS) have participated.
The courses were organized in Lilongwe and Blantyre, and a course in the district of Balaka is in preparation. Held by the local staff of DREAM, which over the years has become an expert on the topics covered, the lessons have been in the national language and thus easily accessible to all.
A great commitment and seriousness of the participants have always characterized these courses. The questions that arise are many. Sometimes students also work in the evening or during breaks, taking advantage to rehearse a lesson, study the most difficult topics, turn into plays what they have learned, to be able to communicate easily in the villages they come from. To discuss, to learn new things encourages each one of us and opens up new paths in the fight against AIDS and stigma, supported each time by new, valuable allies.