Publications
International Activity Report 2011
Scaling Up HIV Treatment
Kenya 2011 © Sven Torfinn
Charles Sako, from Nairobi, Kenya, shows an image of himself in 2005, when he began antiretroviral treatment. Read Charles' story at his blog on My Life with HIV.
Getting Ahead of the Wave of New Infections
In 2000, Doctors Without Borders/Médecins Sans Frontières (MSF) began to provide HIV treatment to a small number of people in Thailand, South Africa and Cameroon, at a time when very few had access to treatment in developing countries. Skeptics said it couldn’t be done, claiming that antiretroviral (ARV) medicines were too expensive, and fragile health systems would not be able to cope.
Today, MSF provides treatment to 220,000 people in 23 countries. In total, eight million people in developing countries are on treatment. While that is still less than half the number of people who need treatment, it is a testament to the huge progress made in the past decade.
In that time, MSF has learned how to reach more people with better care. Ensuring people have access to treatment early on, and before they get ill, helps people stay healthy in the long run. Providing medicines with fewer side effects makes adhering to treatment easier. Entrusting treatment to nurses working in clinics not only brings care closer to where people live, but also helps overcome medical staff shortages. Making sure people can receive HIV and tuberculosis (TB) care in one clinic, from the same health worker, at the same time, is one way to rein in the dual epidemic.
Two further ingredients have been vital to getting treatment to more people: lowering the price of drugs, and raising the funding needed to pay for them. But both are under threat.
Grace’s story
Homa Bay, Kenya
Grace works as a peer educator at the Homa Bay clinic in Kenya: she gives health talks and assists patients before they attend consultations. Her story demonstrates the impact that scale-up of ARV treatment can have.
In 2003, after falling pregnant, Grace decided to take an HIV test. She tested positive:
"I was given PMTCT [prevention of mother-to-child transmission of HIV], and I was very happy to give birth to a healthy child. She is now seven-and-a-half, and healthy and active. She is in class two at school and doing very well.
"I have six children. Three of them are HIV positive and are receiving care. And I have six grandchildren. I encouraged their mothers to use the PMTCT services and only one is HIV-positive.
"Even though they are on treatment, you wouldn’t suspect that my children were sick. They are healthy and active and can do their work. I too live a normal life. I am happy that I can see my grandchildren."
Progress under threat
The price of HIV treatment has come down dramatically since 2000 – by close to 99 percent. This has been possible because of competition among manufacturers of generic medicines, primarily in India, where there were no patents to block the production of more affordable versions of proprietary drugs.
But with international trade rules now forcing India to grant patents, the production of affordable versions of the newer generation of HIV medicines—which many people will need as their illness progresses—looks increasingly bleak.
MSF will continue to support efforts to keep the door open for the production of generic medicines, particularly in India, which are so crucial to keeping down the cost of treatment.
On the funding side, HIV treatment has also hit major roadblocks. Even before the global economic downturn, donors had begun to turn their back on financing global health. In late 2011, because of insufficient funds, the Global Fund to Fight AIDS, Tuberculosis and Malaria—created in 2002 as a 'war chest' to fight the pandemics—had to cancel a funding round for the first time ever. While the Global Fund has since announced that it is back open for business, this crisis is just part of a wider trend of cuts to health financing. Much more sustained funding will be required to begin turning the epidemic around.
Keeping HIV Medicines Affordable
More than 80 percent of the medicines used by MSF to treat HIV are Indian generics, and MSF relies on producers in India for drugs to treat other diseases and conditions as well. India is the 'pharmacy of the developing world': millions of people rely on affordable, quality generics produced in India to stay alive.
But the source of affordable medicines is under threat of drying up. Patent protection in India already means that generic versions of newer HIV medicines will be blocked from production, and we cannot expect to see any dramatic price drops unless urgent action is taken to overcome barriers. India’s patent law has pro-health flexibilities to limit some of the negative impact, but even this is under attack. As we write, the European Union is pursuing a free trade agreement with India that could further harm generic production, and large pharmaceutical companies like Novartis are attacking the pro-health measures in India’s patent laws through the courts.
The struggle for lifelong access to affordable medicines will continue, and MSF will be at the forefront of this effort to ensure people in our projects and beyond have the medicines they need to stay alive.
Opportunity amid the challenge
Yet, while the challenges grow, the opportunities at this moment could not be more promising.
In 2011, news from the scientific community confirmed what people living with HIV had long assumed: getting people on treatment early reduces the likelihood of transmitting the virus by 96 percent. This breakthrough has forever changed the discourse surrounding HIV/AIDS, putting an end to old debates of whether tackling the epidemic through treatment or through prevention is the best approach. Treatment itself is a form of prevention.
In several of our programs, MSF has been looking at ways to make use of the latest scientific findings. In South Africa, our team is piloting an innovative approach, not only scaling up treatment dramatically in order to save lives, but also using treatment as a way to reduce new HIV infections in the community. The pilot project in Uthungulu district, in KwaZulu-Natal, the province hardest hit by HIV, seeks to demonstrate the feasibility of scaling up testing, providing treatment to people in an earlier stage of the disease’s progression, and increasing uptake of prevention methods. The aim is to reduce HIV and TB-related illness, as well as to cut the number of new HIV infections.
Policy-makers seem to be recognizing the opportunity to get ahead of the wave of new infections. At the United Nations in June 2011, all governments committed to ensuring 15 million people are reached with treatment by 2015—this means nearly doubling the number who have access today. But these same governments have failed to come through with their financial commitments to turn these targets into reality.
MSF continues to focus on working in countries most affected by HIV, and in those countries that struggle the most to offer appropriate care, like the Democratic Republic of the Congo and Myanmar, where the proportion of people on treatment is abysmally low.
By documenting both the progress and the threats we see on the ground, we are pushing for renewed political commitment to HIV treatment, backed up by predictable financing of global health, and for access to the affordable medicines needed to keep people alive in the long run. MSF is still grappling with the HIV/AIDS epidemic, and is committed to ensuring more people can get better treatment, sooner.
Kenya 2011 © Sven Torfinn
Charles Sako, an HIV patient in Kenya, takes a dose of ARV treatment.
Care in the Community
"I was here in 2001, when we were first starting patients on ARVs, and the ones that were coming were very sick, most were in wheelchairs. But today most of our patients look well, and most walk to the clinic."
Nicholas Oucho is a clinical officer with MSF at Homa Bay district hospital, in Kenya. Between appointments, he talks about the positive impact MSF’s HIV program has had on the lives of people living here, on the shores of Lake Victoria, in western Kenya.
More than 10,000 patients now regularly make their way up the hill to MSF’s HIV clinic. As Oucho says, "The program has done a lot to help the lives of patients. But we need to build capacity and improve the quality of care in local sites. By building capacity, we will encourage patients to go to the facility nearest them."
It is estimated that anywhere between 13,000 and 29,000 people living in Homa Bay and neighbouring Ndhiwa district are not accessing the care they need. From the hills above Homa Bay, one of the obstacles to access becomes clear—houses sprawl across the countryside, and it is hard to see where one village ends and another begins. This is a rural, but densely populated region, and the distance to the nearest HIV clinic can be prohibitive. Many do not get to a clinic until they are already very ill, prejudicing their chances of survival.
Bringing Treatment Closer to People
The Kenyan government has set a national objective for 80 percent of HIV patients to be able to access treatment at their nearest medical facility. An MSF team supports HIV services in eight health centers in the area with regular visits.
The team provides mentoring to the permanent staff, offers counseling to patients and traces patients who have missed appointments.
MSF has decided to focus more on building the capacity of these local sites. "We want to try and make each center independent of the main hospital," says Catherine Moody, MSF head of mission in Kenya.
By investing in staff, laboratory services and counseling, MSF hopes to support the provision of quality care, get more people onto treatment, and improve patients’ adherence to treatment throughout the two districts. These kinds of strategies, and others, such as community drug distribution programs, offer the possibility of meeting the medical need and allowing us to expand treatment, not only saving the lives of those individuals already infected with HIV, but also, as we now know, preventing the virus from spreading—effectively offering protection from HIV to the whole community.
MSF’s Access Campaign works to help our medical teams give quality care to our patients through promoting the development of new vaccines, medicines and tests, and challenging existing barriers to treatment—such as cost—for patients in poorer countries. To learn more, visit www.msfaccess.org or follow @MSF_access on Twitter.
