If HIV treatment standards in the global South do not keep up with standards in wealthy nations, history will not judge well current efforts to expand treatment in resource-limited settings, Dr Kevin M De Cock, outgoing head of HIV at the World Health Organization, told the 2009 HIV Implementers’ Meeting in Windhoek, Namibia, earlier this month.
"The world cannot allow a permanently two-tiered system of global AIDS treatment with late initiation of outmoded drugs reserved for the South. Nor can we hide behind lack of knowledge or the attitude of 'let's wait and see'," he told the meeting in a plenary address.
He called on PEPFAR and the Global Fund to move quickly to support a large, simple trial of the best time to start treatment in resource-limited settings, and rejected the notion that earlier treatment was not feasible due to the current financing gap facing the Global Fund.
“If public health is rooted in the science of epidemiology, its philosophic values are equity and social justice,” he said. "We are entering perilous ethical and political waters, and current practice for poor people of colour in the global South will not be judged well by history if it does not evolve with science and practice in the richer North,” he said.
Dr De Cock then invoked the Tuskegee experiment. He said that others would certainly draw analogies between the current practice of care the world was offering millions of people with HIV in resource-limited settings – failure to diagnose most, and late and sub-optimal treatment to the remainder – and Tuskegee, the most infamous biomedical experiment ever in the US, in which poor African-American men with syphilis were left untreated.
Just like Tuskegee, there is no longer any question that earlier treatment in Africa would save lives – even though how early and which optimal regimen are
unclear. But Dr De Cock said that with millions of people in these programmes, the world ought to be able to do research to find the answer – and he proposed conducting a large simple trial with the support of PEPFAR and the Global Fund.
“It is unacceptable, in view of what is at stake – millions of lives, billions of dollars – that despite over three million people in the world on ART, we cannot definitively answer the question of when to start treatment.
“There is ethical as well as medical need for a randomised controlled trial to determine optimal starting criteria in Africa, including assessment of the impact of immediate treatment on tuberculosis incidence.
“PEPFAR and the Global Fund could resolve these questions once and for all through applied research under field conditions, through a large simple trial, for example, with hard endpoints such as tuberculosis, AIDS, death.
“Some argue such a study is not needed because we will never have resources to treat more people earlier with better drugs. This is unpersuasive; rationing of health care is a universal reality but let rationing decisions be made transparently, with the involvement of all stakeholders, based on scientific understanding of cost and benefit,” he said.
He noted that other changes to make treatment more comparable to that in industrialised countries – such as moving away from the drug d4T, which is rarely used in the North, to the easier-to-tolerate tenofovir, would also cost more money (tenofovir currently costs four times more than d4T).
Ultimately, Dr De Cock believes that HIV treatment should go the way of TB treatment with one, or a few, global, once-daily, first-line regimens containing “the best drugs”.
“That it can be done was shown by the tuberculosis community a decade ago. Today, if you get tuberculosis in Jakarta, Kampala or Los Angeles, you receive the same four-drug regimen,” he said.
Notably, Dr De Cock said that when the current four-drug TB regimen was chosen, “drugs with unacceptable toxicity such as thiacetazone were phased out because collectively we said 'Enough, now,' even as some argued against change citing cost or drug resistance.”
Doing all this may take “imaginative thinking, renewed advocacy, innovative financing, and more efficient implementation”.
“Global health needs global financing,” Dr De Cock said. “Raymond Biggs, New York Commissioner for Health a century ago, famously said that public health is purchasable and every society can determine its own death rate.”
“Universal access will slip through our fingers unless we reframe it in the broader context of all health-related Millennium Development Goals. From disjointed prevention and treatment of the past we must move towards more intelligent use of ART for treatment as well as prevention, guided by science, stratified by individual serostatus, with all infected persons knowing their rights to health, including sexual and reproductive health. What else is universal access?” he said.
He concluded by quoting Robert Kennedy: "'Only those who dare to fail greatly can ever achieve greatly.'
“That is the spirit of PEPFAR and the Global Fund. And for all here working on the front lines, far from the halls of power, remember that all public health is local and change is often driven from small places – places that you may not find on any map of the world, but where ordinary people take risks. There is comfort in those other words of Robert Kennedy: 'Few will have the greatness to bend history itself; but each of us can work to change a small portion of events, and in the total of all those acts will be written the history of this generation.'
“To which one could add: And so also, one day, will be written the history of this pandemic.”
Further information
An extended version of this article, also reviewing Dr De Cock’s comments on epidemiology and prevention, appears in the June 29th edition of HIV & AIDS Treatment in Practice, NAM’s electronic newsletter on HIV treatment in resource-limited settings. Follow this link to download the pdf version.
The full text of the speech and Dr De Cock's accompanying slide presentation are available at the WHO website.