This originally ran as a guest post on the Speaking of Medicine PLoS community blog
By Sharonann Lynch, HIV/AIDS Policy Advisor, Campaign for Access to Essential Medicines, Doctors Without Borders/Médecins Sans Frontières
As the 18th International AIDS Conference (IAC) winds down here in Vienna, the word in the hallways is that the science is in: earlier initiation of treatment and improved antiretroviral (ARV) drug regimens are better for individual patients and communities, and may even ultimately reduce transmission of HIV. Some of the new data presented at the conference come from MSF’s project in Lesotho, where I worked from 2006 to 2009.
In a two-year study of 1,128 patients from rural Lesotho, where the government has adopted new World Health Organization (WHO) guidelines, patients starting treatment earlier (at CD4 count <350) were 70 percent less likely to die, 40 percent more likely to remain in care, and more than 60 percent less likely to be hospitalized compared with those started when their disease was already advanced (CD4 <200).
After all the talk and spectacle, many of us—people with HIV/AIDS, clinicians, researchers, and activists—will have to go back to reality: to townships and rural villages still ravaged by the virus; to congested clinics with waiting lists for treatment; and to rich country capitals where donors are ignoring the science and retreating from their commitment to fully fund universal access to treatment, telling us to get used to this new reality—we are in the midst of global economic recession, after all.
At the conference there was a lot of talk about cost-effectiveness and efficiency as a means to mitigate funding shortfalls. Sure, we need to avoid waste and the obscene number of consultants and reports that sit on shelves in Washington, Geneva, and London. But how do the actual people fit in to these crude calculations? What is the cost-benefit to their lives, families, and communities?
We are advocating for a different vision: for patient-centered efficiencies that will increase access to treatment and reduce the burden on patients in taking toxic drugs, reporting excessively to health facilities, and traveling great distances to seek care. We also want efficiencies to reduce the requirements on the health system, for example through task-shifting and community-based, out-of-facility approaches to drug dispending and social support. And economists are telling us these sorts of efficiencies will even be cost-saving in the long run.
So how do we build on Lesotho’s example and get more patients on treatment? Here are some forward-looking ideas that could change the game:
- Invest in rigorous research and pilot projects to explore the feasibility and impact of “treatment as prevention.” Treatment is increasingly understood to have major prevention benefits, in addition to reducing HIV- and TB-related illness and death.
Support research to radically simplify and optimize the package of ARV treatment, including:
- Dose optimization: If shown to be effective, reducing the dose of some ARVs could potentially treat up to one-third more patients without a cost difference.
- New drug development: Develop new ARV drug delivery platforms and slower-releasing drugs, which could help to decrease the burden on patients as well as the cost per patient per year.
- Accelerate commercialization of point-of-care diagnostics: new instrument-free, point-of-care CD4 cell count blood tests, once available, could be rapidly deployed to the field for use in identifying more patients at the lowest levels of care, while we redouble efforts to develop a point-of-care viral load test.
- Create and implement a financial transaction tax (FTT): billed by some as the “Robin Hood tax” (including activists at IAC dressed up in feathered green hats and bows and arrows), a tiny tax of 0.005 percent on foreign currency transactions could generate an estimated $33 billion per year for global health needs and other issues affecting the developing world. Such a “tax and treat” strategy could deliver the sufficient, regular, and predictable funding to pay for scale-up, provided donors make good on their existing commitments to the Global Fund and other financing mechanisms.
- Ensure an enabling policy environment to usher in these new innovations, including aggressive use of Trade-Related Aspects of Intellectual Property (TRIPS) flexibilities and an effective patent pool.
If we want to bend the curves of the HIV epidemic, we should seriously consider and put into action radical game-changers such as these.
Learn more about MSF’s efforts for HIV/AIDS at aids2010.msf.org