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Rebuilding the Ship as We Sail: Knowledge Management in Antiretroviral Treatment Scale-Up

In a recent film about the Napoleonic wars, a frigate suffers heavy damage and loss of life after a withering canon barrage from a faster and more heavily armed privateer. Listing with a damaged hull and broken mast, the crew assumes they will return to port to rebuild. In the captain's mind, however, his duty is clear and their options are singular: they must rebuild as they sail. In meeting the challenge of providing equitable care to the 40 million people in the world living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), the course of the disease makes the goal doubly demanding, as it has become increasingly clear that the future path of this pandemic will run through the poorest and most densely populated areas of the world — areas that are the least well equipped to respond. Africa is home to 10% of the world's population but accounts for almost two-thirds of global HIV infections, so the greatest burden will be borne by countries with already weakened and in some cases failed health systems. Without proper health systems in place, is an effective strategy for scaling-up antiretroviral treatment (ART) possible? There is only one answer to this question: we must rebuild health systems as we confront the epidemic.