The International

According to a report presented to the United Nations in Geneva on 30 September, almost half of people in need of treatment for HIV and AIDS in low- and middle-income countries are now receiving it. More than 4 million people in low- and middle-income countries are now on a regime of antiretroviral treatment (ART) to control the virus, which is a million more people that the previous year’s figures.

The report, jointly published by the World Health Organisation (WHO), the United Nations Children’s Fund (UNICEF) and the Joint United Nations Programme on HIV/AIDS (UNAIDS), collected data on four critical factors affecting the success of combating HIV and AIDS: treatment and care, testing and counseling, women and children, and most-at-risk populations.

The aim of the report, entitled “Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector,” is to indicate how much progress has been made towards achieving the Millennium Development Goal (MDG) that focuses on the reversal of the spread of HIV/AIDS, in the hopes of eventually eradicating the disease. This report specifically looks at the target that demands that by 2010 there should be “universal access to treatment for HIV/AIDS for all those who need it.”

Hope and fear in equal measure

Data collected up until the end of 2008 suggests that out of the estimated 9.5 million people in need of ART to control the virus, 42 per cent have access to it. This is a substantial increase on the 2007 figures, which measured treatment delivery at 33 per cent of people in need. In Sub-Saharan Africa, where two-thirds of all HIV-infections occur, there were signs of enormous progress towards achieving the MDG, with a higher-than-average figure of 44 per cent of those in need able to access treatment.

For testing and counseling, the figures also show improvement. In 2008, 93 per cent of all countries offered free testing at public sector health facilities. In 39 countries, the total number of HIV tests more than doubled.

More focus on programmes for the prevention of mother to child transmission (PMTCT) meant that in 2008, 45 per cent of HIV-positive pregnant women received anti-retroviral drugs to prevent transmission to their children, up from 35 per cent in 2007. Mr Jimmy Kolker, chief of UNICEF’s HIV/AIDS programme division, warned at a press conference that there are still many obstacles to overcome: “Loss to follow-up remains high – many women who come for antenatal visits do not get tested, or if they do, they don’t come for their results, and if they do get their results, many do not return for the medication.”

Some experts suggest that the majority of people who have HIV are still unaware of their status. This may be particularly true for groups with high risk of transmission, such as sex workers, men who have sex with men (MSM), and drug users. Forty-one out of 149 low- and middle-income countries routinely tested injecting drug users, 44 tested MSM, and 65 tested sex-workers. Due to legal barriers and discrimination, these groups have the least access to care. Discrimination, and the criminal status of each of these groups in many countries, makes directed programmes difficult to plan and implement.

“This report shows tremendous progress in the global HIV/AIDS response,” commented Ms. Margaret Chan, Director-General of WHO, in a press release. “But we need to do more. At least 5 million people living with HIV still do not have access to life-prolonging treatment and care. Prevention services fail to reach many in need. Governments and international partners must accelerate their efforts to achieve universal access to treatment.”

However, providing universal treatment is not easy. Because HIV can mutate once in a person’s body, treatments constantly need to be amended. For example, Ms Thembisa Mkhosana is a mother living in Khayelitsha, a poor district on the outskirts of Cape Town, South Africa, with a high incidence of HIV. According to Doctors Without Borders/ Médecins Sans Frontières (MSF), Ms Mkhosana found out she was HIV-positive in 2001 and two years later began treatment at the MSF clinic. She initially responded well to treatment. But after developing resistance to her first-line regimen (the first combination of anti-retroviral drugs that she was prescribed), she was given a different combination of ARVs. Now she has developed resistance once more, but the cost of the third-line regimen is too prohibitive. “If there’s no such thing that can help me, I know that I’m going to die,” she said. “And then who is going to look after my children?” In the MSF clinic in Khayelistsha, one in five patients is in a similar position to Ms. Mkhosana.

International AIDS Society (IAS) President Julio Montaner, who earlier in the year at the IAS conference in Cape Town, criticized the G8 leaders for their “silence” over renewing their commitment to stopping the spread of HIV, is concerned that reports of the improvements made towards universal coverage might result in a complacent, “mission-accomplished” attitude, causing focus to withdraw from the realities of those like Ms Mkhosana. Mr Montaner commented, "While significant, these recent gains are also fragile and urgently require increased and sustained financial commitments by the G8 and other donors to reach the goal of universal access to HIV prevention, treatment, care, and support.” He urged for invigorated focus and funding to continue efforts to prevent and treat HIV in resource-poor countries.

It is estimated that in 2010, an investment of US$7 billion is necessary to meet treatment goals alone, and an additional US$25 billion to address the goals of prevention and care of for children orphaned by HIV. The economic crisis has negatively affected funding, which is raising fears that the gains might lapse in the coming years. In Thailand, in the aftermath of the Asian economic collapse, support for schemes such as free condoms for sex workers wilted, causing much progress to be undone.

Governments are already showing signs of caution. Tanzania reported budget cuts for HIV/AIDS programmes, and Uganda said it does not intend to start new patients on treatment next year. Botswana, a long-time flagship for treatment and prevention, plans to stop enrolling new patients for HIV treatments by 2016.

The financial crisis will also have more insipid effects. Higher levels of poverty spur riskier behaviours, such as prostitution and drug use. Additionally, the effectiveness of ART is greatly reduced if good nutrition is not maintained.

Maintaining the gains

Much has been learned since the emergence of AIDS in the early 1980s. The first case was diagnosed in San Francisco when an outbreak occurred among the gay male community. Considered to be a disease that only affected homosexual men, human rights groups accused governments of not directing enough funding and research into developing effective treatments. It soon became clear that AIDS affected people from all classes, races, and genders. In Sub-Saharan Africa, the disease was discovered to be particularly widespread. Massive funding from governments and international bodies was then put into developing medicines to counter this global epidemic that was claiming thousands of lives.

Thirty years on, no cure for HIV/AIDS has been developed. A test conducted earlier this year in Thailand initially renewed hope in the development of a vaccine. A clinical trial showed the new vaccine regimen to have had a modest impact in preventing HIV transmission among 16,000 adults, reducing transmission by 31%. Whether these results are significant has been contested as the most positive means of interpreting the statistics was employed and other factors that may have resulted in reduced transmission rates, such as education, were not taken into account.

Treatment, however, is available that has allowed those who are HIV-positive to live longer, better quality. Yet in developing countries, many still die young because they do not have access to necessary forms of treatment, for reasons of finance and logistics. Similarly, transmission from mother to child has almost been eradicated in developed countries, but continues to occur in low- and middle-income countries.

Prevention strategies

Even though testing is a precondition for prevention, treatment, and care, many individuals have resisted knowing their HIV status because of fear; fear that the test will be positive, fear that treatment is not possible or not available for economic or access reasons, and fear of stigma and discrimination. International bodies, like UNAIDS, and governments following UN guidelines directed resources into testing and counseling, focusing especially on provider-initiated testing, which aims to introduce testing and counseling into more general and routine healthcare.

Civil society groups also are playing their role in testing and counseling. In Cameroon, peer education projects aimed at 15- to 24-year-olds have raised awareness among the young. In Uganda and Kenya, trained counselors go door-to-door to conduct home-based testing and counseling, reaching those who might not choose to go to health care facilities, while also dealing with issues of disclosure between partners. In South Africa, creative awareness-raising strategies, including national testing weeks headed by celebrities and sex worker advice at truck stops, have been yielding good results. The Tutu-tester has become a common and welcomed site on the streets of Cape Town. It is a van that goes to different neighbourhoods conducting free testing and counseling as part of a general health package, which also tests for diabetes and hypertension “to make it less scary.” Project coordinator Nienke van Schaik said, “When you make it quick and efficient, people are willing to undergo testing.”

Mr Etienne Kembou, WHO’s Programme Officer for HIV/AIDS in Cameroon, said that AIDS is no longer stigmatised like it was in the 1990s. He added, “Across the board there is an increase in testing because young people know they can benefit from interventions if they know their status.”

Sweetness Mzoli, who runs Kwakhanya, an organisation which helps care for 300 patients in Khayelitsha, has noticed that over the last year resistance to testing has dropped, “There’s a lot of men out there who want to talk about their status.”

Access to treatment and care

Some challenges to access to medicines have already proved surmountable, such as the reduction in the cost of ART by between 10 and 40 per cent. According to MSF, ten years ago AIDS treatment for one person for one year cost US$10,000, mainly because medicines were patented. With the advent of cheaper generic versions manufactured in several countries, including India and Brazil, treatment for one year for one person now costs US$80.

This situation is changing. International trade laws have allowed for the newer medicines to be patented in these countries and newer, much-needed HIV treatments will not be available to those in developing countries. When one in five patients develop resistance to their first-line regimen within the first five years of treatment, and of those, a further one in four again develops resistance to their second-line regimen within two years, access to the more expensive second- and third-line regimens is becoming increasingly more urgent.

Yet, earlier this year, the pharmaceutical company Novartis attempted to legally contest a section in India’s Patent Act that prohibits the practice of “evergreening,” which is when pharmaceutical companies change the formula of existing medicines very slightly, thereby renewing the patent and prohibiting producers of generic versions from creating cheaper alternatives. Pharmaceutical companies maintain that the cost of research and development requires them to safeguard their profits in order to feed the money back into their laboratories for more effective treatments or an effective vaccine to be developed.

Humanitarian groups claim that pharmaceutical companies direct more money towards marketing than research and accuse them of putting profit above saving lives. On the same day the UN report was published, MSF urged pharmaceutical companies to create an HIV-drug patent pool, which would be a scheme for sharing information in exchange for royalty payments, for which some companies have shown interest. This would not only accelerate research and development in the search for more effective medicines and even a vaccine, but would also make more affordable versions of much needed drugs available much sooner than otherwise would be possible. “This opportunity comes at a crucial time,” commented Dr. Eric Goemaere, MSF’s medical coordinator for South Africa. “Programs have developed resistance to their medicines and need to switch to newer, more effective drugs now. Because these are either unavailable or unaffordable, patients face a return to AIDS death row as treatment options dry up.”

Much progress has been made over the last decade towards universal access for HIV treatment, but there is still a long way to go. Governments and humanitarian organisations serving the developing world must be able to access existing medicines that can save lives, but in a way which does not limit the ability of pharmaceutical companies to continue to create more efficient medications or, more promisingly, a vaccine.