Access to HIV treatments and diagnostics is improving in some parts of Asia, the Annual Conference of the Australasian Society for HIV Medicine heard last week in Cairns.
Thailand scales up
In Thailand, where 740,000 people are living with HIV/AIDS, the gains have been significant. The Thai Red Cross and the Ministry of Public Health supply all HIV-positive women with AZT and nevirapine during pregnancy and milk formula after the birth of their infants.
Dr Chris Duncombe of the HIV Netherlands Australia Thailand (HIVNAT) Research Collaboration told the conference that this initiative has reduced mother-to-child transmission to less than two percent.
Other advances in Thailand have resulted from the availability of cheap generic antiretroviral drugs. Dr Duncombe said that the triple combination called GPO-VIR (d4T/3TC/nevirapine) now costs Baht 1200 (₤18) per month, which is affordable to the majority of people living with HIV in Thailand.
Family-centred programs are providing 1500 HIV-positive parents and children with treatment, in an attempt to stem the family and social breakdown which follows the death of adults in their reproductive years. Thailand currently has an estimated 300,000 AIDS orphans.
Antiretroviral drugs, which usually require a co-payment by the patient, are also provided to many people through public hospitals and research institutions. Subsidised treatment is being made available through a network of nearly 500 hospitals throughout Thailand. HIV NAT is conducting a range of clinical trials at sites in Thailand. Click here for details.
With the aid of money from the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, the Thai Government aims to have 30,000 people on antiretroviral therapy by next year.
To accompany the broader availability of anti-HIV treatments, access to HIV antibody testing and CD4 cell testing is also being improved in Thailand. The Thai Red Cross currently operates a clinic in Bangkok with conducts 8800 HIV tests per year and offers CD4 cell testing. Three new Red Cross clinics, which will provide CD4 cell testing and stage of disease assessment, are due to open in other parts of the country.
Low-cost monitoring
The need for laboratory tests to accompany expanded access to antiretrovirals was addressed at the ASHM conference by Prof. Suzanne Crowe of the Burnet Institute.
Prof. Crowe reviewed the range of low-cost CD4 cell and viral load tests which have been developed:
- A CD4 cell assay known as Dynabeads T4-T8 System is made by Dynal Biotech ASA in Norway.
- A CD4 cell assay called the Coulter Manual CD4 Count Kit is made by Beckman Coulter in the US.
- CD4 assays which use flow cytometry technology are generally expensive and require considerable technological infrastructure to establish. Nevertheless, Prof. Crowe said that the Pan Leukogating assay is being used in South Africa, where the cost per test is as low as US$5 (₤3), and Indonesia is one of several countries experimenting with the FACS Count assay. The quoted price of FACS Count is US$20 but this may fall when reagents are ordered on a regular basis.
- A viral load test which provides an ultrasensitive measure of reverse transcriptase (RT) called ExoVir is made by Cavidi Biotech in Sweden. Comparison with standard assays has shown that this low-cost viral load test is very accurate when viral load is above 10,000 copies/ml, although less exact below that level. The ExoVir is also highly accurate for most viral subtypes and currently costs between US$10-20 (₤6-12).
- An ultrasensitive p24 assay used to measure viral load is made by Perkin Elmer in the US. Evidence suggests it is less sensitive compared with the Cavidi RT assay.
The two low-cost CD4 assays both require a laboratory technician to count cells while looking through a microscope. Due to the labour-intensive nature of this work, Prof. Crowe told the conference that these tests are only appropriate for relatively low caseload areas, where fewer than 50 tests are conducted weekly.
Recent studies comparing the low-cost ‘manual’ CD4 assays with ‘gold standard’ CD4 assays available in western countries have found that the low-cost tests perform well, although they underestimate CD4 cell numbers by 60-120 cells. Both the Dynal Biotech assay and the Coulter assay provide accurate CD4 counts when blood samples have been stored at mild room temperature for up to 72 hours; manufacturers recommend tests be performed within six hours.
Monitoring in India and Indonesia
A partnership between the Burnet Institute in Australia, and the Laboratorium Klinik Prodia (a private laboratory), Udayana University and non-government organisations in Bali, Indonesia, has successfully provided people living with HIV/AIDS (PLWHA) with low-cost CD4 cell and viral load monitoring.
The Burnet Institute has also been working through the Australia-India Council to collaborate on training, treatment, technology transfer and quality assurance programs. Prof. Suzanne Suzanne Crowe has conducted a train the trainer program on the use of anti-viral drugs and her colleague Dr Mandy Dunne has established low-cost HIV monitoring in Chennai and Mumbai, India.
The cost of providing manually performed CD4 tests in Indonesia and India is between US$5-7 (₤3-4) per test.
Prof. Crowe told www.aidsmap.com that this collaborative work may be in doubt. “We are working hard to provide transfer of technology of appropriate tests for countries within the Asia-Pacific region particularly,” she said. “It will depend on the success of our recent application for funding to the new ACH2 (the former National Centre for HIV Virology Research) as to whether we can continue this work or not.”
Basic information and support still needed
Despite these advances, an HIV-positive woman from Jakarta reminded the ASHM conference that many people and health care professionals remain ignorant about HIV/AIDS. She described the prejudice and exclusion she experienced after testing HIV positive. Screened for HIV without consent, the woman was shunned by relatives after the testing doctor disclosed her status to family and advised them incorrectly that HIV may be transmitted through the sharing of household items.
Although now on treatment in Jakarta and in contact with support groups, the woman highlighted the need for education and support as well as treatment for people living with HIV in Indonesia.
Further information on this website
Monitoring where resources are limited - overview of key issue and research on low cost diagnostics.
References
Crowe S et al. Laboratory monitoring of HIV infection using low-cost manual assays. Fifteenth Annual Conference of the Australasian Society for HIV Medicine, Cairns, plenary 4, 2003.
Duncombe C et al. HIV/AIDS in Thailand: current status and response to the epidemic. Fifteenth Annual Conference of the Australasian Society for HIV Medicine, Cairns, Symposium – Experiences in Implementing Care and Treatment in Resource Poor Settings, 2003.
___________. Living with HIV infection in Indonesia. Fifteenth Annual Conference of the Australasian Society for HIV Medicine, Cairns, plenary 4, 2003.