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.
are being threatened by the global recession, political opposition, the
inadequacy of health systems, and concerns about drug side-effects and
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.
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).
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.
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.
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.
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
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
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.
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
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.”