Lessons from Years Past, Priorities for the Future
Kenya 2005 © Brendan Bannon
In early June, world leaders and global health officials gathered at the United Nations for a summit meeting on HIV/AIDS. Among the outcomes was a new treatment target, a plan to get 15 million people living with HIV/AIDS on antiretroviral (ARV) treatment by the year 2015.
It’s currently estimated that 6.6 million people are on ARVs today. Doctors Without Borders/Médecins Sans Frontières (MSF) was one of several organizations calling—through advocacy efforts, through public communications, and though reports based on first-hand experience treating HIV in the developing world—for a massive scale-up of treatment. In that regard, the “15 by ’15” pledge was welcome news. But it is just one step in a much larger effort, one of numerous measures MSF believes necessary to ensure that funding for the effort is in place, that effective medicines are available to those who need them, and that the global health community adopts medical guidelines that give the greatest number of people the best possible chance at longer healthy lives.
The necessity, and the potential impact, of a massive scale-up has become even clearer with new research from the National Institute of Health showing that treating HIV/AIDS reduces by 96 percent the risk of sexual transmission of HIV—which is to say, treatment is prevention. That means scaling-up treatment will benefit individuals and limit the number of new infections. “This opens up a whole new world where we not only treat the individual with ARVs, but we can aim to reduce new infections at the community level, too,” says Dr. Isabelle Andrieux-Meyer, HIV advisor to MSF’s Access Campaign
Kenya 2011 © Sven Torfinn
MSF began providing ARVs for HIV/AIDS in 2000 in Thailand. The following year opened HIV projects in Cameroon, Cambodia, South Africa, and elsewhere, and today, MSF provides ARVs to more than 170,000 people in 19 countries. From the outset, the results were dramatic. “I remember when I first started treating people with antiretrovirals in Mozambique,” recalls Dr. Gilles Van Cutsem of MSF’s South Africa office. “People were so ill and weak as a result of their illness that they sometimes weighed no more than a few kilos and were often carried into the clinics by their grandmothers. But one year later, after starting ART, those same people were just walking into clinic to ask for their pills themselves. It was amazing.”
Chronic disease treatment is not a static process, however. Improvements can and must be made, new policies sought, new initiatives pursued. Based on its experience, MSF has identified a host of measures crucial to continued and sustained progress against the disease. They include:
Treat earlier: Most people in developing countries are not started on treatment until their CD4 cell count, an indicator of immune system strength, drops to or below 200 cells per cubic millimeter of blood. By then, many are ill and at risk of opportunistic infection. MSF supports new World Health Organization guidelines that recommend starting treatment when CD4 levels drop to 350. Data from MSF’s programs in Lesotho showed that people who started between CD4 200 and 350 were 68 percent less likely to die, 63 percent less likely to need hospitalization, and 39 percent less likely to drop out of care, compared to people who began at CD4 200 or lower. (In the US, for reference’s sake, treatment starts when CD4 counts hit 500.)
Better drugs: In developing countries, the most commonly used first-line drug regimen contains stavudine (d4T), which can cause intolerable side effects. The WHO now recommends safer drugs such as zidovudine (AZT) or tenofovir (TDF), which MSF is moving towards using in all of its projects, and which has proven cost effective because there aren’t the same number of side effects to treat. Better drugs are also easier to take; fixed-dose combinations reduce the number of pills patients need, simplifying treatment and enabling better adherence.
Kenya 2011 © Sven Torfinn
Prevent transmission to infants: In wealthy countries, mother-to-child transmission (PMTCT) of HIV is below two percent. But in nations that lack the same services and protocols, PMTCT causes a significant portion of new infections. To lower the numbers, donors must support countries trying to institute HIV services alongside antenatal and maternity care, creating effective drug regimens for pregnant women. “We know how to stop the vast majority of babies from acquiring the HIV virus,” says Dr. Marianne Gale, an MSF pediatrician. “These babies don’t need to get infected.”
Decentralize services: Moving care from hospitals to health centers and community health posts—and closer to patients’ homes—allows MSF to reach more people. “That way [we] reach all those people who normally wouldn’t get treated because they couldn’t afford the transport to a health clinic or couldn’t afford the time away from home and work,” says Dr. Marcella Tomassi from MSF’s program in Swaziland.
Support community-based dispensing: Enlisting patients to assist each other has also shown benefits. In Tete, Mozambique, for instance, members of patient-led “community ARV groups” take turns picking up and distributing medicines, decreasing traffic at understaffed health centers and significantly increasing adherence rates.
Treat HIV and TB: This is crucial given the high rates of often fatal co-infection in many countries. By integrating HIV and tuberculosis services in Khayelitsha, South Africa, MSF increased proper diagnoses of TB and halved the time it takes to get HIV and TB co-infected people on ART. In MSF’s program in Shiselweni, Swaziland, TB detection almost doubled after HIV/TB services were integrated.
Shift tasks: The WHO recommends “task shifting” to overcome health care worker shortages and bring treatment closer to patients. In many MSF programs, nurses and clinical workers start patients on treatment and lay counsellors provide testing and adherence counselling. Reviews of programs in Malawi, Lesotho, and South Africa showed no decrease in the quality of medical care.
Kenya 2011 © Sven Torfinn
GREATER NEEDS, DWINDLING SUPPORT
Having grown out of an international effort to fund HIV treatment, two bodies—the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US Government-led President’s Emergency Plan for AIDS Relief (PEPFAR)—provide treatment to 81 percent of people now on ART.
But for the first time in a decade, overall funding for HIV decreased in 2009.The Global Fund faces a shortfall of several billion dollars, while PEPFAR, facing its own funding reductions, is hinting at reducing support for some programs and handing over others to health systems that aren’t ready to administer them. Some countries with high HIV burdens are being forced to scale back treatment ambitions.
In Malawi, for instance, where MSF has worked for more than a decade and 63 percent of those in need have been started on ARVs, the government's plans to further expand and decentralize treatment will be delayed due to funding gaps. Zimbabwe’s plan to implement new WHO guidelines is also being delayed. In Uganda, where 300,000 people badly need to be started on treatment, spotty funding has meant that only pregnant women can start treatment at the earlier CD4 threshold. And in the Democratic Republic of Congo, where only 17 percent of those who need ARVs get them and only two percent of pregnant women receive PMTCT services, the treatment initiation rate fell 18 percent in 2010.
The inescapable truth is that if treatment is delayed, denied, or not started, lives are lost. “If there is reduced funding, it will mean more people will die and we will have more orphans,” said Catherine Mango, a woman living with HIV/AIDS in Kenya. Donor governments must therefore reaffirm prior commitments to support access to HIV prevention, care, and treatment.Developing country governments must respect commitments such as the Abuja Declaration on allocating at least 15 percent of GDP to health. Innovative funding mechanisms should also be explored and promoted; a proposed financial transaction tax, for example, could lead to millions in revenue with a miniscule levy on international bankers’ transactions.
On the research and development side, more affordable medicines will help get more people on treatment. Competition among generic manufacturers helped reduce prices dramatically and, according to PEPFAR, helped reduce costs by more than $300 million over four years. It must not be restricted through intellectual property measures and overly stringent free trade agreements. And pharmaceutical companies can keep costs down by joining the Medicines Patent Pool, which askspatent holders to make patents available to generic companies in exchange for a royalty payment—allowing for easier production of needed three-in-one fixed-dose combination pills.
Kenya 2011 © Sven Torfinn
THE NEXT DECADE: A CLEAR MISSION
HIV/AIDS has claimed more than 25 million lives over the past 30 years. We must meet the challenges presented by a global treatment scale up and we must fiercely reject any double standard in care—and the complacency that would allow us not to do more.
In the decade ahead, aggressive research and innovation is needed to develop more effective treatment strategies and simpler and better medicines and tools. With funding, dedication, and political will, it is possible to provide better drugs at lower prices; to develop drugs specifically suited for children with HIV/AIDS; to design more effective delivery mechanisms, such as long acting formulations that could be administered weekly or monthly; to develop simpler tests to measure CD4 levels or diagnose TB; and to take other steps to insure more people get the chance Luis Junior Mariquele of Mozambuque got when he started treatment. “Antiretroviral drugs have changed my life from negative to positive,” he said recently. “Without these drugs I would not be on this planet.”