September 29, 2009

Mozambique 2007 © Benjamin Bechet

An HIV-positive woman waits with her child at the district hospital in Chamanculo.

With a dire need for newer medications, a shortfall in funding and no increases on the horizon, the AIDS emergency in the developing world is far from over. Doctors Without Borders/Médecins Sans Frontières (MSF) spoke out at the International AIDS Society Conference held in July in Cape Town, South Africa, to push for urgent action.

Two kinds of treatment

“I’m so worried now because I don’t know what is going to happen to me,” says Thembisa Mkhosana, a mother of two who lives in Khayelitsha, on the outskirts of Cape Town, South Africa.

Thembisa discovered she was HIV-positive in 2001 and began receiving life-extending antiretroviral drugs (ARVs) through MSF’s clinic two years later. She responded well to treatment and was able to return to work and take care of her children. After showing signs of drug resistance, Thembisa was switched to a second set of ARVs. Again, she developed resistance. She now needs a third combination of ARVs to keep her alive, but the price of newer drugs puts them beyond her reach.

“If there’s no such thing that can help me, I know that I’m going to die,” she says. “And then who is going to look after my children?”

In the Khayelitsha clinic—one of MSF’s longest-running HIV/AIDS programs—nearly one in five patients needs to switch to newer medications within five years of starting treatment. Of those who switch, one in four develops resistance again two years later.

This happens to people living with HIV/AIDS everywhere, not only in South Africa. But a third drug combination that could keep Thembisa alive is available only to those who can afford the treatment. The result is two kinds of treatment for HIV/AIDS: one for those living in wealthy countries, and one for those in the developing world.

In the US and other wealthy countries, HIV/AIDS now resembles a chronic condition, and patients generally have access to an increasing variety of medications when they develop resistance to their current drug combination. In the US, Thembisa could live to around 70 years old . In Africa, where the majority of people with HIV/AIDS are, those in Thembisa’s position are likely to face a much earlier death.

Access to new drugs is imperative

“What we are seeing in Khayelitsha is what we will soon see throughout Africa if there is not a focused push for urgent change,” says Dr. Eric Goemaere, medical coordinator for MSF in South Africa.

In addition to having a lack of alternative drug regimens, the one ARV regimen that is affordable in most poor countries contains a drug that causes serious side effects and is rarely used in wealthy countries. But unlike the first generation of HIV/AIDS drugs, prices for newer drugs are kept high—up to 30 times the price of first-regimen drugs—by medicine patents that prevent the production of more affordable generic versions.

Some pharmaceutical companies are trying to stifle competition in generic drug production, for example, by challenging certain provisions of some national patent laws. In August this year, Swiss company Novartis launched a new legal challenge to eliminate a key public health safeguard in India’s patent law that currently opens the way for access to more affordable generic drugs.

Section 3(d) of India’s Patents Act, 1970, prohibits 'evergreening'—the practice by pharmaceutical companies of making trivial changes to existing medicines in order to extend the period of their patent, thereby stifling the generics market and keeping drug prices high. Novartis’s challenge seeks to limit the effectiveness of section 3(d).

India has been a major source for generic drugs, and a main provider to MSF’s HIV/AIDS programs around the world.

HIV/AIDS treatment at a crossroads

MSF was one of the first organizations to provide treatment for HIV/AIDS in the developing world, starting with projects in Thailand and South Africa in 2000. Today, MSF treats 140,000 people living with HIV in more than 30 countries. This has been possible in large part because MSF helped drive down the cost of first-generation ARVs, which are now available in generic versions.

New challenges to treatment in these countries are threatening hard-won and future progress—HIV/AIDS treatment is at a crossroads. And, not unlike 10 years ago, when many people said treating AIDS in Africa was impossible, there is little awareness among the international community of the urgency of this issue. This is why MSF has spoken out at the International AIDS Society Conference and elsewhere and continues to press funding bodies, donor countries, and others to act.

“Seeing a patient you have been treating since 2003, and now this patient is failing on her second combination, you feel you are a failure,” says MSF nurse Mpumi Mantangana. “We are feeling like our hands are tied. There is nothing we can say to Thembisa because it’s she who needs answers from us.”

The need for political will during an economic crises

Four million people in developing countries receive ARVs, and at least six million more are in immediate need of treatment, but are not receiving it, according to UNAIDS. Extending HIV/AIDS treatment to everyone in need and offering them effective treatment with alternative drug regimens will require much more investment and political will. However, the international HIV/AIDS effort has been compromised by the reaction of world leaders to the economic crisis.

HIV/AIDS funding is stagnating and the prospect of universal access to treatment may be withering. The two main funding sources for HIV/AIDS in developing countries—the Global Fund and the US government’s PEPFAR program—respectively report a $3 billion shortfall and no increase in funding.

In response to these dramatic political and economic changes, countries ravaged by HIV/AIDS are scaling back their ambitions: Tanzania reports significant budget cuts; some health care providers in Uganda say they do not intend to start new patients on treatment; and Botswana says it will stop enrolling new patients by 2016. This trend is likely to continue unless the international community reaffirms its commitment for universal access to effective HIV/AIDS treatment.

“It’s a question of choice for national and donor governments,” says Dr. Tido von Schoen-Angerer, director of MSF’s Campaign for Access to Essential Medicines. “Will they give poor people just a few extra years of life or the same chance for long-term survival as people with HIV/AIDS in rich countries?”

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