Alive at Five: Lessons Learned from AIDS Treatment in Resource-poor Settings

By Dr. Alexandra Calmy, Advisor to MSF's Campaign For Access To Essential Medicines

Doctors Without Borders/Médecins Sans Frontières (MSF) has been providing antiretroviral (ARV) treatment to people living with HIV/AIDS in developing countries for nearly five years now.

With over 57,000 patients on ARVs in a variety of resource-poor settings, MSF is constantly re-evaluating and evolving its approach to AIDS treatment. We strive to reach more people by simplifying treatment, rethinking treatment strategies, and relying more on paramedical staff as treatment providers. But the accomplishments to date have led to a series of new clinical and political challenges.

First, a lack of adapted diagnostic tests and treatments for babies and young children means that caregivers and medical staff struggle to provide adequate care for the growing number of children needing ARVs.

At the same time, some of the adult patients who have been on treatment for a few years now are finding their drugs are no longer working. The nature of the HIV virus means that patients cannot stay on one single regimen indefinitely, and experience from developed countries shows that it is indeed unrealistic to expect this. More and more individuals will need to be switched to so-called second-line treatment – yet medical teams don't know at what point it is best to make this change. Part of the problem is that there is as yet no simple and affordable means to monitor the presence of the virus in the person's blood, the best indicator of whether or not treatment is still working.

When the decision is made to switch a patient, care providers will need one or two practical standardized second-line combinations. Since many people will have been on a first combination for years and may have accumulated resistant virus before being switched, the second-line treatment will need to be robust: it will need to work despite resistance to the first-line combination. The ideal combinations could be stored at room temperature and would have few side effects. Today's second-line regimens do not fulfill these criteria; what's more, they cost up to 20 times more than the first-line medicines, a fact that will need to change dramatically.

But it may be that the strategies we have used to promote access to first-line treatment will be insufficient to cope with the new challenges. These include the full implementation of the World Trade Organisation's patent rules through the TRIPS (Trade-related Aspects of Intellectual Property Rights) Agreement, which has consequences for the availability and affordability of medicines.

The stakes in the global fight against AIDS are high – they far exceed the current funding commitments to the Global Fund to Fight AIDS, tuberculosis and malaria, for example. Government funding for AIDS is nothing short of insufficient. This is evident in the area of AIDS research: from direct experience, MSF staff know that there is an urgent need to do clinical and operational research that would benefit people living with HIV/AIDS in developing countries. But is the research conducted in Africa today really designed to respond to the needs of people with AIDS on the continent, or will its benefits only be felt where patients or their health systems can afford state-of-the-art solutions?

There is no easy answer to how we can expand treatment to more people who need it. We are currently only touching the tip of the iceberg, and will need to find strategies to cope with the ever-growing queues of people waiting to be treated. How will we, or any treatment group or government program, reach and care for all patients in need of ARVs in a particular location, for example?

Let's face it: collectively, WHO, national governments, donors and non-governmental organizations have not reached the objective of providing the best treatment for people living with HIV/AIDS. AIDS is a complex chronic disease about which medical professionals have more questions than answers. But the international political environment is constantly evolving, and priorities change. A recent case in point is the avian flu, which has opened governments' eyes about not letting patents stand in the way of protecting lives. This potential threat has suddenly mobilised hundreds of millions of dollars, whereas AIDS, a pandemic that kills eight thousand people a day, is not getting the attention it deserves.