The provision of HIV treatment for patients in Africa has now started to reap real public health benefits, the Fifth International AIDS Society Conference in Cape Town heard this summer.
However these are being threatened by the global recession, political opposition, the inadequacy of health systems, and concerns about drug side-effects and resistance.
While there was a lot of new information on treatments, almost a majority of presentations at the IAS conference looked at the provision of HIV treatment to poor countries, and particularly to Africa.
Figures presented by the World Health Organization (WHO) at the conference estimated that four million people worldwide were receiving antiretrovirals (ARVs) by the end of 2008 (nearly three million of them in sub-Saharan Africa) compared with three million a year previously (two million in Africa).
Several papers found that recent increases in ARV provision had resulted in dramatic declines in other diseases. One study found that the prevalence of tuberculosis (TB) in patients with HIV in one Cape Town township had gone down by nearly two-thirds in just two years and that as a result overall TB prevalence had shrunk by 20%, due to an increase in ARV provision to those in need from 12% to 90% between 2004 and 2008.
Another study from Uganda found that malaria cases in people with HIV had fallen by 75% in the four years of an ARV treatment programme while one from KwaZulu Natal found that mortality in babies under two fell by nearly 60% between 2001 and 2007, due to fewer mothers with HIV dying.
ARV provision produced social and economic benefits, too. One study of HIV patients in the Johannesburg area found that the proportion with a job increased from 27% before starting treatment to 47% after three years on treatment.
These successes were accompanied by concerns that ARV treatment programmes might not be sustainable, however. A report issued by the international charity Médecins sans Frontières (MSF) before the conference warned that “financing for HIV/AIDS is stagnating”.
Using South Africa as an example, it found that the global recession and resultant cuts in the government’s health budget had led to a halt in the recruitment of new patients to ARV programmes. One study found that more than half of South Africans eligible for treatment had to wait over a year to actually receive it and another that 20% of patients eligible for ARVs died waiting for them.
MSF’s Head of Mission in South Africa, Eric Goemaere, said: “All around us, clinics stop enrolling because there are just not enough ARV supplies.”
Given this, it might seem like a luxury to raise the CD4 count at which to start treatment from 200 to 350, in line with developed country guidelines, or to substitute cheap but toxic drugs like d4T with more tolerable but expensive ones like tenofovir.
Dr Francois Venter, president of the South African HIV Clinicians Society, warned treatment activists that demands for tenofovir needed to be considered in the light of poor progress towards delivering treatment in general. “A lot of my patients die without even having access to d4T,” he said.
It is therefore important to continue to look into ways of providing ARV treatment more cheaply. One way is to save on monitoring: data from the large DART trial in Uganda found that prescribing ARVs on the basis of clinical symptoms rather than CD4 counts resulted in 30% more deaths or HIV-related illnesses but that doing this could mean that over 30% more people could be put on ARVs.
Another way is to “task shift”, training lower-paid health workers to provide what doctors normally do. A study from Lesotho was able to prescribe the more expensive regimen of tenofovir, 3TC and efavirenz to patients with CD4 counts below 350 due to savings by using nurses instead of doctors.
There was a strong defence of the large global HIV programmes by several figures at the conference, after a couple of years in which programmes like the US PEPFAR initiative and the Global Fund for HIV, TB and Malaria have been accused of diverting money away from strengthening health systems in resource-poor countries and from other health goals such as reducing child mortality and non-communicable diseases like diabetes.
Francois Venter said that the most efficient way of achieving a worldwide reduction in child mortality was to put all HIV-positive mothers on ARVs while Michel Kazatchkine said that a quarter of the Global Fund’s grants had gone towards strengthening healthcare systems.
Former UNAIDS special envoy to Africa, Stephen Lewis, said that the critics of HIV funding were in danger of dismantling the progress that had been made in global health. “You can’t permit an argument in favour of slicing the pie differently rather than demanding a larger pie to be used to justify a terrible reversal in public policy,” he said. “The gains we’ve made and the momentum we’ve achieved are being put at risk.”