The need to expand treatment as donors turn back on HIV
In recent years, international donors of global HIV/AIDS have slowly stagnated or reduced their funding. The Global Fund and the US government’s PEPFAR programme face stark funding shortfalls, which will have a tangible impact on the ability to scale up treatment to reach the agreed target of having 15 million people on treatment by 2015. While more than eight million people were on treatment by the middle of 2012, another nearly seven million people remain in urgent need of treatment and will die in the next several years without it. It is imperative to offer treatment to everyone who needs it, especially now that science has shown treatment not only saves lives, but also can also drastically reduce the risk of someone passing the virus on to others.
The latest science shows that HIV treatment makes people less infectious to others – HIV treatment is also HIV prevention. So on top of saving lives, treating HIV can also prevent the spread of the virus. This makes scaling up treatment to all those in need all the more urgent. HIV treatment can also prevent the virus from being passed from a mother to her baby during pregnancy, at birth or through breastfeeding – a fact that has been known for years. Prevention of mother-to-child transmission (PMTCT) strategies – where both pregnant HIV-positive woman and her newborn baby are given antiretroviral medicines (ARVs) – can prevent the baby from acquiring HIV. It’s vitally important that countries implement new World Health Organization guidelines to prevent thousands of new infections in babies.
People living with HIV/AIDS who are treated earlier in their disease progression have a better chance of staying healthy and not developing potentially deadly diseases such as tuberculosis, the main killer of people with HIV. It is crucial that countries start people on treatment earlier than has been the case so far. The drugs people are treated with are important, too – countries should phase out the drug stavudine which can cause intolerable side effects, in favour or the better-tolerated drug tenofovir. People are more likely to stick to their treatment when they take drugs that cause fewer side effects, which benefits their health in the long term.
With no cure for HIV/AIDS, people need to be treated for life. As they develop side effects or resistance to drugs, they need access to newer and more potent medicines. However, newer drugs are more expensive than the antiretrovirals (ARVs) most people are currently taking. First-line ARVs have come down in price by 99 percent over the last decade, thanks to generic manufacturers in India, Brazil and Thailand being able to produce these drugs that were not patented in those countries. However, the newer drugs are now increasingly being patented in these countries, meaning that prices will not come down the way they did for the earlier generation of drugs. For countries to access more affordable versions of these new drugs, they will need to start overriding patents or find other ways to overcome the high prices created by patent monopolies on the newer drugs.
Tuberculosis (TB) is the number one killer of people living with HIV/AIDS; due to weakened immune systems, they are much more likely to develop the disease. Unfortunately, diagnosing TB in people with HIV is difficult and the lack of effective diagnostic tools means many people go undiagnosed. Drug-resistant forms of TB (DR-TB) are even more difficult to diagnose and treat. The drugs to treat DR-TB can have intolerable side effects that make it difficult for patients to continue taking them, and some TB drugs can also interact with HIV medicines and so cannot be taken at the same time. Integrating HIV and TB care is critical to lessening the burden on people infected with both HIV and TB, and ensuring they stay on treatment.
Diagnostics and treatment for children with HIV lag behind because pharmaceutical companies don’t have the market incentive to develop products for children in poor countries, where over 90 percent of children with HIV live. Diagnosing HIV in children under 18 months is difficult, because the mother’s antibodies in the child’s blood can interfere with the test; at the moment, the only way to test infants is to use a DNA-based diagnostic tool that is too expensive for most developing countries. Treatment is also complicated – drugs are often not approved for use in children or do not come in child-friendly formulations. And the paediatric formulations that do exist are often difficult to store and administer in resource-limited settings, and can be extremely unpalatable, making them even more difficult to give to children.
A big challenge in scaling up antiretroviral treatment in developing countries is ensuring that access to treatment doesn’t disrupt lives or put too much strain on the health system. Moving care from hospitals into local clinics has proven to be a successful way to get more people on treatment and help them stay in care long-term. ‘Task shifting’ – or allowing nurses and health workers to start patients on treatment and dispense medicines instead of doctors – can help reduce the burden on health care systems where there is a critical shortage of health workers. Integrating services for both HIV and tuberculosis, requiring fewer check-ups of stable patients, and allowing a group of peers to support each other, also eases the strain.
Innovation in both drugs and diagnostics is urgently needed to help scale up treatment and monitor patient progress effectively. Exploring different approaches in the way a drug is manufactured - including the production costs of the active pharmaceutical ingredient (API) (which is the main cost of a drug) and the actual amount of API used in a drug - can help both reduce costs and reduce potential side effects. Drug formulations are also being explored that may only need to be taken once a week or month. Simple and easy-to-use tests that require an easily-sourced sample – like a cheek-swab or blood from a finger prick – for diagnosing and monitoring HIV/AIDS and diagnosing tuberculosis, are also urgently needed to improve scale-up and care in resource-limited settings.