Achieving the full potential of antiretroviral treatment as a prevention method will require governments to take political decisions about long-term finance, and be brave enough to lead rather than follow the scientific agenda, according to speakers at Controlling the HIV Epidemic with Antiretrovirals: From Consensus to Implementation, a conference that took place in London last week.
The conference, organised by the International Association of Providers in AIDS Care (IAPAC) and the British HIV Association (BHIVA) in partnership with UNAIDS and Public Health England, brought together experts for discussion of how to expand treatment access in order to realise the full benefits of antiretroviral therapy (ART) in preventing new HIV infections.
Citing the example of Malawi’s policy to provide treatment to all pregnant women regardless of CD4 cell count – Option B+ – Catherine Gotani Hara, the Malawian Minister of Health, told the conference: “Option B+ was led by policy, not guided by science – Malawi decided to do it.”
“We decided as a country to tailor the treatment for Malawi,” she said. A shortage of CD4-counting machines and the need to simplify treatment guidelines so that nurses could initiate therapy led policymakers to decide that treatment for all pregnant women would be the most suitable approach in Malawi.
“We said we need to go closer to the people. We looked at our workforce – not enough specialised nurses and doctors – and decided to decentralise treatment to the lowest cadres of health care workers without compromising quality,” she went on.
“My big problem was persuading the Minister of Finance to spend money,” she said. What persuaded the Ministry of Finance to permit the expansion of treatment? “Tax take! If they can’t work they can’t pay tax,” she argued to the Ministry of Finance.
But, cautioned Professor Alan Whiteside of the University of KwaZulu-Natal, “40% of adults in Swaziland are engaged in subsistence agriculture, they don’t pay taxes. We need to start making an economic and political case for treatment and we need to understand that we are working in a competitive environment – a competition between AIDS, malaria, TB and health systems.”
“I think the exceptionality of AIDS is over. Finance trumps health every time. We need to be smarter with our advocacy. There is a tension between the short-term and the long-term and between one-year budgets and lifetimes,” he went on.
Arguments about the impact of treatment on the workforce form part of what Reuben Granich, UNAIDS Treatment and Care Advisor, called “third-generation economics”. A study carried out by Harsha Thirurmurthy in Uganda found that people with CD4 cell counts above 500 worked almost six days a month more than people with CD4 cell counts below 200 – and their children were more likely to stay in school.
Today’s investments may have long-run impacts lasting 30 to 40 years that manifest in higher rates of development, less poverty and lower birth rates as a consequence of extended education, Thirurmurthy suggested.
The squeezed middle
David Wilson, head of the World Bank’s HIV programme, cautioned that some countries receiving high levels of donor assistance to support treatment will face the need to commit much higher levels of domestic finance to HIV programmes as their economies grow and they move into the middle-income country bracket. This may also have implications for drug costs, due to licensing agreements which impose higher charges on middle-income countries for some products.
Furthermore, he expects to see programmatic costs rise as countries achieve higher coverage, despite the economies of scale demonstrated by PEPFAR when clinical sites mature and treat larger numbers of patients.
“The last 20 to 30% is always hardest to reach in marketing, and we know that it is more expensive to reach key populations – in some cases up to ten times more expensive,” he told the conference.
Getting the mix of interventions right is likely to provide the best value for money, and achieving the maximum impact may not always require universal treatment, he argued. A modelling study of the South African epidemic, for example, found that circumcision of 60% of males and expansion of treatment under current national guidelines to reach half of all people living with HIV achieved the same reduction in HIV incidence as universal treatment for all people diagnosed with HIV, but would cost $5 billion less over the course of the decade.
Decisions about how to spend money will become especially pressing in concentrated epidemics, where treatment already claims the majority of the HIV budget, in most Latin American countries, and in South Africa, where treating everyone with a CD4 cell count would cost more than the entire sum allocated to health in 2013, he went on.
Successes from Kenya
New data from Kenya released in September underline the impact of investment in rapid scale-up.
Deborah Birx, Director of the US Centers for Disease Control Global HIV/AIDS Program pointed to the doubling in the proportion of the adult population in Kenya who have tested for HIV over the past five years and the decline in HIV prevalence from 10.5 to 6.4% in the 25 to 35 age group as evidence of what can be achieved with rapid scale up of counselling, testing and treatment. Kenya also boasts an HIV suppression rate that exceeds the performance of the United States: 78% of adults on treatment have a viral load below 1000 copies/ml.
About half the decline in incidence since 2004 in Kenya is explained by ART, modelling suggests, and further work is needed to determine the extent to which the pace of treatment scale up in various African countries explains variations in HIV incidence and mortality, she concluded.