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Scaling up HIV Treatment in Peru: Applying Lessons from DOTS-Plus
Global Health Sciences Literature Digest
Published February 20, 2007
Journal Article

Sebastian JL, Munoz M, Palacios E, Espiritu B, Mestanza L, Chalco K, Llaro K, Guerra D, Shin S, Bayona J. Scaling up HIV Treatment in Peru: Applying Lessons from DOTS-Plus. J Int Assoc Physicians AIDS Care (Chic Ill). 2006 Dec;5(4):137-42.


To analyze barriers to antiretroviral (ART) enrollment in Peru's HIV program using Peru's past experience in DOTS-Plus to treat multi-drug resistant tuberculosis.

Study Design

This was an assessment of barriers in Peru's HIV program. Based on the assessment, a team of consultants worked with HIV health-service providers and the Ministry of Health (MOH) to redesign the enrollment process. The study design is a pre/post-intervention evaluation.


20 hospitals that provide HIV care in Lima and Callao, Peru.


Information was obtained from physicians, nurses, and health technicians responsible for HIV treatment programs in the major hospitals. The unit of analysis was the number of patients initiating antiretroviral therapy.


A team of consultants from Socios en Salud (SES), a non-governmental organization that supports the Peruvian DOTS-Plus Program, was hired to evaluate the enrollment process in the HIV Program. The SES team of nurses conducted a series of sessions with staff responsible for HIV treatment programs. The sessions involved workshops to discuss the problems in enrolling patients into HIV treatment and to propose solutions. Additionally, the SES nurses and health promoters visited each of the major hospitals and observed the process of patient care. The team identified operational aspects that were both similar to and different from the DOTS-Plus program to determine which obstacles could be addressed by adapting DOTS-Plus strategies, and which problems needed fresh approaches. Based on these assessments, several obstacles were identified, in which practical intermediate and long-term solutions were implemented to address them.

Primary Outcomes

The primary outcome was the rate of enrollment into the ART program and the percent coverage of the population in need of ART.


The following challenges were identified: establishing inter-institutional cooperation; decreasing loss to follow-up; medical stabilization prior to initiation of ART; providing adequate human resources; and ensuring medication supply. Short-and-long-term activities were identified and implemented for each obstacle in order to help improve the enrollment process for patients. As a result of implementing those activities, the rate of enrollment increased from 124 patients/month in the first nine months of the program to 226 patients/month in the last seven months--an increase of 83%. This strategy achieved 38.5% coverage of the population in need.


The authors conclude that the investment in an efficient and effective ART rollout system in which barriers to enrollment and patient care are eliminated will provide the appropriate structure for a strong HIV program. Future challenges of case retention, ensuring adherence, side-effect management, and good reporting can only be successfully addressed when built on such a strong and stable infrastructure.

Quality Rating

There is no formal system in place to rate a program evaluation such as this. However, this study had the following limitations: no details were provided regarding the hospitals included in the assessment (such as number of hospitals, geographic location, demographic of patients); and no details were provided on how patients provided input into the enrollment process. Without this information, it is difficult to determine the comprehensiveness of the assessment.

In Context

There has been concern about the overzealous rollout of HIV treatment programs, which may result in treatment failure and increased HIV resistance.(1,2) However, programs cannot be curtailed by early program limitations to the point that care is not given to patients who urgently need it. Therefore, learning and improvement must be an ongoing process during the scale-up of ART treatment programs.(3)

Programmatic Implications

This is an important article for countries whose antiretroviral rollout efforts are just beginning or have stalled. Identifying barriers to care is critically important, and the methods used by SES can be applied elsewhere. In countries that have successfully implemented similar treatment programs for other diseases, such as DOTS-Plus, it is important to review what made these programs successful. Ministry of Health officials and other stakeholders should ensure that local capacity and knowledge are included in the process of finding solutions to challenges in antiretroviral treatment programs.


  1. Lange JM, Perriens J, Kuritzkes D, et al. What policymakers should know about drug resistance and adherence in the context of scaling-up treatment of HIV infection. AIDS 2004; 18(Suppl 3):S69-S74.
  2. Popp D, Fisher JD. First, do no harm: a call for emphasizing adherence and HIV prevention interventions in active antiretroviral therapy programs in the developing world. AIDS 2002; 16: 676-678.
  3. Bailey C. Rebuilding the ship as we sail: knowledge management in antiretroviral treatment scale-up. Bull World Health Organ 2004; 82: 798-800.