Dr Joep Lange, President of the International AIDS Society and co-chair of the forthcoming 2004 Bangkok International Conference on AIDS, gave the principal keynote address to the workshop. There had been real progress since 1996 towards widespread access to antiretrovirals which, he claimed, were the only cost effective treatment for HIV and AIDS.
Dr Lange felt, after reviewing the alternatives, that it was one of the most positive things that could be done to address the problem of HIV and AIDS in Africa and other countries, including India.
Education alone did not work: in Botswana, the epidemic had grown to be massive despite enormous efforts to raise awareness. There is still widespread reluctance to use (male) condoms, which were still not as available as they need to be, and female condoms are not really an attractive alternative. Use of ARVs to prevent sexual transmission might be more likely to work than microbicides, and could incidentally be more woman controlled, but still need to be proven effective and safe for widespread use. Vaccines are still "10 years" away, after many years for which this had been promised, without guarantees they would work. As for preventing mother-to-child transmission without treatment for the parents he had to ask, is it worth it?
Political commitment remains a major challenge and he quoted a saying, Of all the ills that kill the poor, none is as lethal as bad government. Sometimes the public health care sector was incompetent, corrupt, or simply not extensive. On the cost of care, he acknowledged that the problem can seem overwhelming and asked how Europe or North America would cope with 20% of the adult population HIV positive. He acknowledged that HIV is just one of many problems faced by societies and governments.
Immediately, he proposed a model based on accredited treatment centres that could be used to establish expertise, sustained by contracts with companies, NGOs, embassies, and others, bringing private sector know-how to bear in turn on meeting the needs of public sector services. This is one of the goals of PharmAccess International, an organisation he founded and works for.
On the risks of the drugs, he said, It is better to let two out of a hundred people die of HAART-toxicity, because of minimal monitoring, than a hundred out of a hundred die of HIV because HAART is not available.
To move from treating thousands to treating millions, it would be necessarily to tackle a series of interrelated needs, all at the same time. These included:
- Robust drugs [he was concerned that nevirapine (NVP) and lamivudine (3TC) are each vulnerable to single mutations, making regimens like NVP/3TC/d4T (Triomune) less than ideal as a treatment regimen]
- Drug distribution
- Cheap and simple monitoring
- Expertise and manpower
- A simple regimen [favouring fixed dose combinations where possible]
- Financing health care
- Prevention of HIV transmission
- Operational research [on how to implement care, treatment and prevention]
This he saw as needing a concerted global effort, based on a broad coalition of participants, including public and private sector members, with clear divisions of responsibility and accountability for action.
The International HIV Treatment Access Coalition, formed in December 2002 with WHO providing the secretariat, is intended as a global focus for such efforts, and further information is available from its website at: http://www.itacoalition.org/
Dr Jos Perriens, of WHO, traced the emergence of WHOs present commitment to expanding access to ARV treatment. UNAIDS had rightly highlighted the need for a multisectoral response to HIV and AIDS; WHOs proper role was to mobilise the health sector. While the possibility of ARV treatment had begun to be discussed from 1995, WHO had not really kept up with the need for a health sector response to support treatment. This was now transformed, with a strong commitment to the UN General Assemblys target of putting 3 million people on treatment by the end of 2005.
Dr Perriens estimated that 5 to 6 million people in developing countries now urgently need ARV treatment, 4 million of them in Africa, but only 300,000 have access now, of whom 50,000 are in Africa. The target figure of 3 million was based on an assessment of what might be delivered, based on what is being done in other health fields, such as childhood immunisations, TB treatment, and so on.
Reasons to focus on ARV treatment included:
- It greatly improves quality of life and life expectancy, decreases absenteeism, hospital admissions, cost of OI treatments
- It preserves human capital for development with an impact on education, the transmission of life skills, prevention of orphanhood
- It strengthens prevention through increased uptake of VCT, PMTCT, and behaviour change. He claimed that in Khayelitsha, near Cape Town, the rate of condom use is now the highest in South Africa, following an increase in take-up of VCT which may have been twelve-fold or more.
Without it, he foresaw that in three generations, southern Africa could be reduced to the present state of central Africa, in social and economic development terms.
It was important to set goals high enough to be worth achieving: set them too low, and youll never get there.
There were five components, as he saw it, to what was needed.
- Simplified decision making with standardised protocols and simplified monitoring. WHO supports this approach.
- Optimised use of human resources, delegating from physicians to nurses and other health cadres. If there are no complications, the doctor doesnt need to see them.
- Involving people with HIV and community members in delivering treatment.
- Cost minimisation strategies to deal with the costs of drugs and monitoring, including support for alternative monitoring technologies and simpler clinical monitoring.
- Integrating ARVs in existing structures with other interventions including HIV testing, PMTCT, OI management and TB treatment.
In practical terms, countries needed to produce national treatment guidelines, decide on a delivery model that can be scaled up and is appropriate to existing systems level of development, develop a short and medium term implementation plan, ensure best use of public and private health service infrastructure and human resources.
This is not complicated if one builds on ones strengths rather than focuses on ones weaknesses.
WHO itself would:
- Advocate for action on treatment access
- Propose norms, standards, materials for action, making full use of materials developed by other agencies where possible
- Support individual countries in their planning
- Support a culture of collaborative action that involves all major stakeholders in the health sector [with ITAC as the basis for this]
- Develop a global procurement plan for ARVs, together with UNICEF and the International Dispensary Association IDA [a non-profit agency based in the Netherlands, which supports governments, NGOs and faith-based services in procuring essential drugs and medical supplies]
- Identify, document and publicise best practice.