Thursday, June 30, 2011

Can we treat our way out of the HIV epidemic?

Today afternoon I attended a very engaging and thoughtful debate. Can we treat our way out of the HIV epidemic?
The debate was at Makerere University's School of Public health where the presenters were up and coming Ugandan Centers for Disease Control (CDC) fellows. And so, the perspectives were largely Ugandan.
It was a debate akin to a secondary school debate with proponents and opponents for the motion of the day. And a very topical one indeed, seeing as it is ,that its thirty years since the onset of the HIV/AIDS pandemic which started way back in early 1980s among American gay couples.
Well, it emerged at the debate that there is scientific proof to show that the HIV/AIDS epidemic can be eliminated through a universal 'test and treat' approach where all are tested for HIV and those found positive are put on AIDS drugs.
Scientists have shown ,through modelling, that universal access to voluntary counselling and testing for HIV and putting all eligible patients on antiretroviral therapy(ART)can end the HIV epidemic while controlling for behaviour change and prevention efforts. The recent National Institutes of Health study among HIV discordant couples shows that starting early on ART can reduce the HIV transmission risk by 96% proving that that ART is both a treatment and prevention tool. An observational study conducted in Rakai,Uganda by Steven Reynolds which followed 51 discordant couples showed than none of them contracted HIV while the positive partner was on AIDS drugs. In Botswana, 90% coverage of prevention of Mother to Child Transmission(PMTCT)eliminated mother to child transmission of HIV altogether.
Those arguing that we cant treat our way out of the HIV epidemic hard a far easier task of the afternoon.
They simply made the case that we dont have the resources to treat all those in need of ART in terms of the financial,human,pharmacuetical and laboratory and other associated resource needs. That we dont have the health systems in which to dispense the drugs in Sub Saharan Africa even if they were suddenly available , in Uganda for instance, and that many countries have showed limited capacity for absorbing AIDS aid. The Uganda treasury recently returned 50 billion shillings of unutilized funds for AIDS drugs. The latest Auditor General's report shows that many AIDS drugs have expired in our national medicine stores and will have to be destroyed.
That the socio-cultural and behavioural drivers of the epidemic will continue to spread HIV even if all those eligible are put on anti AIDS drugs. The proponents though showed that those on ART have shown a 78% reduction in risky sexual behaviour. That ART drug adherence would be problematic and lead to an even more complicated situation of drug resistance due to posible low drug adhrence necesitating the use of second line drugs which a lot more expensive and not widely available in Sub Saharan Africa. And that stigma is a barrier to testing and treatment for HIV in Africa and would be a huge hurdle for universal coverage efforts.
And where will the finances come for treating all those in need of ART? How sustainable can it be fiscally speaking? Simple: the usual donors will pay for it! And by usual donors is meant PEPFAR,Global Fund, World Bank etc. In short, the west. This was the response of Sarah Nakku one of the proponents. Of course it is alot more complicated than that. She however argued that the west has a direct self-interest in combating HIV in Africa given the globalised world we live in. A traveling Ugandan can have breakfast in Kampala, lunch in London and dinner in New York.
And do we have health sytems within which to deliver these drugs in Sub Saharan Africa or Uganda at least? According to the proponents, yes we do. That an infrastructural skeleton exists in Uganda and all we have to do is beef it up. Read, pay doctors better salaries,equip hospitals with labs and drugs and that you dont necessarily need medical degrees to treat HIV since lower cadre health workers can be trained to do the job etc. Again a little simplistic if only for arguments's sake. And 80% of the generic AIDS drugs are from India ,from where Uganda an mot AIDS-affected countries get the ARVs, which has now asked to stop the production of generic drugs whose patents are help by western pharmaceutical firms.
And then the mainly academic audience weighed in. What if we targeted
specific epidemic drivers such as sex workers,truck drivers and fishermen instead od the entire population came a thoughtful question.
At the 2000 international AIDS conference in Durban South Africa, the west was skeptical about the abillity of African health systems to scale up access to ART because of fears of
drug adherence and weak health systems(again!) but see where we are now. In Uganda more than a half of those in need of ART have it. In other words, the west may be skeptical about mass treatment like it was before the scaling up of ART but it was proven it can be done. That it took truly global efforts to eliminate small pox,river blindness, polio etc and the same can be done for HIV/AIDS. And what is the alternative anway? The risk of not treating AIDS is a lot worse than actually treating it and studies show expenditure on ART is actually an investment in future generations.

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