AIDS breakthrough threatened by budget woes

New discovery brings hope, but will the funds be there?
From Africa Renewal: 
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A patient having her blood tested in Johannesburg, South AfricaA patient having her blood tested in Johannesburg, South Africa: Researchers find that treatment makes people living with HIV far less infectious. 
Photograph: Associated Press / Denis Farrell

After 30 years and over 20 million deaths in Africa alone, US researchers now report that early treatment of people infected with the human immunodeficiency virus (HIV) that leads to AIDS cuts transmission of the disease by over 96 per cent. The news has sent shock waves through the medical and scientific world. Unexpectedly announced by the US National Institutes of Health on 12 May after a six-year clinical trial, the discovery that anti-retroviral drugs (ARVs) can make people living with HIV far less infectious means that humanity finally has the tools to reverse the global epidemic.

The announcement has been welcomed as a "game changer" by Michel Sidibé, the head of UNAIDS, the UN's anti-AIDS agency. The high rate of new infections — almost 2 million in Africa alone in 2009 — he told Africa Renewal, made it impossible for treatment programmes to keep pace. But the recent discovery now gives the continent the potential to make dramatic cuts in new infections and get ahead of the treatment curve.

The $73 million, nine-country study found that beginning ARV treatment shortly after diagnosis reduces the amount of HIV in the body to almost nothing, making it much less likely that people with HIV will infect others. Previously, patients began ARV treatment only in later stages of the disease, which damages the body's natural defences against illness. Although there is no cure for HIV, a combination or "cocktail" of different ARV drugs suppresses the virus and allows the body to recover. The patient must take the drugs for life.

Treatment as prevention

"This finally settles the debate over whether to invest in prevention or treatment," says Mr. Sidibé. "Now we know that treatment is prevention." The study prompted UN Secretary-General Ban Ki-moon to open a three-day conference on AIDS at UN headquarters in early June with the declaration that "today we are gathered to end AIDS."

Nor was it the only good news for Africa, the region hit hardest by the disease. UNAIDS reported at the 8-10 June meeting that AIDS-related deaths, overall infection rates and new infections have dropped in recent years, while access to ARVs has skyrocketed, although it remains well short of the need (see table below).

High hopes hit tight budgets

Having the technology to curb AIDS, however, is not the same as having the political will to do so. Sceptical observers note that total spending on HIV and AIDS programmes is already about $8 billion short of needs and that past pledges to increase spending on anti-AIDS services are unmet. Where the money will come from to put many millions of new patients on treatment, as the study urges, is anybody's guess.

Instead, the breakthrough on treatment comes amidst signs of donor fatigue. After a nearly 10-fold increase in resources for HIV treatment and prevention programmes in African and other developing countries over the past decade — money that has saved the lives of millions — UNAIDS and the US-based Kaiser Family Foundation report that international AIDS funding was essentially static in 2009, at $7.6 billion, the first year ever without an increase. The numbers for 2010 are even worse, showing an actual drop from 2009 levels, the first significant decline in AIDS donor funding since the epidemic began.

"I think the era when we could rely on increased funding for AIDS programmes in developing countries is probably over for good," Kaiser Family Foundation Vice-President and Global Health and HIV Policy Director Jennifer Kates told Africa Renewal. "The only real question is whether funding will hover around current levels or whether last year's drop is the beginning of a long-term decline" — a situation that would make it difficult for people in developing countries to take advantage of the breakthrough.

'Disowned and abandoned'

The tighter budgets are already beginning to bite. In testimony before the US Congress last year, Dr. Peter Mugyenyi, director of the pioneering Joint Clinical Research Centre in Kampala, the first and largest ARV treatment facility in Uganda, praised Washington's multi-billion-dollar AIDS treatment programme, the President's Emergency Plan for AIDS Relief (PEPFAR), for saving countless African lives. Because of funding from PEPFAR, the Global Fund to Fight AIDS, Tuberculosis and Malaria, national health budgets and other donors, the number of Africans on ARVs has risen from fewer than 50,000 in 2002 (see Africa Renewal, April 2005) to about 4.5 million in less than a decade. "The carnage that I and my fellow health care providers used to witness on a daily basis faded as the situation changed from despair and misery to hope."

But he also told the lawmakers that "the twin realities of the [2008] economic crisis and flat-lining of funds for PEPFAR threaten to reverse these highly positive changes and miss opportunities to defeat the epidemic." ARV treatment must continue uninterrupted for life, Dr. Mugyenyi noted, and funding needs to increase as newly infected patients join those already in therapy. Already, he continued, "my institution … is not taking on any new patients. We are forced to turn away desperate patients daily…. Nowadays when new ones reach a stage when they require therapy … they are disowned and abandoned to their fate."

Dr. Mugyenyi agreed with public health experts who argue for increased funding for other deadly diseases in Africa — but not by taking money away from AIDS as some in the West have suggested. He reminded the US legislators that, despite the huge improvement in access to treatment over the past decade, fewer than half of those Africans who need the drugs currently receive them. Other urgent health needs, he said, should be met, "but not at the expense of HIV/AIDS, which needs increased support." He quoted Ugandan Health Minister Jim K. Muhwezi in noting that "concern is growing across the African continent" about the slowdown of international assistance for anti-AIDS programmes, a concern that surfaced before the current cuts.

A patient having her blood tested in Johannesburg, South AfricaAIDS activists demonstrating outside the European Union office in Nairobi, Kenya, to protest a trade agreement that could jeopardize imports of cheap generic medicines from India.. 
Photograph: Associated Press / Khalil Senosi

Doing more with less

But with the means to roll back HIV now within reach, many doctors and researchers have called for radical changes in the global campaign against AIDS in order to do more with less. That would include redefining ARV treatment as a prevention tool and expanding testing to identify people with HIV before they infect others.

An article in the 11 June 2011 issue of the influential medical journal The Lancet called for moving money out of poorly targeted and often-ineffective prevention programmes aimed at changing individual behaviour into ARV-based treatment-as-prevention efforts. The authors argued that greatly expanded treatment programmes would save money over the long term by preventing millions of new infections and deaths.

The Lancet editorialized that paying for such a large increase in drug access, and administering the powerful drugs to tens of millions of additional patients through today's overstretched public health systems, is "a huge challenge." But the discovery that treatment is the most effective prevention, it concluded, presents the world with an unprecedented opportunity to "make a big difference" in the 30-year war against AIDS.

Treatment versus trade rules

Advocacy groups, including the South African Treatment Action Campaign and Doctors Without Borders, point to other factors jeopardizing treatment access. Chief among them are restrictions on the export of cheaper generic copies of patented ARV medicines to African and other poor developing countries.

Generics have been at the heart of the African treatment revolution over the last decade, driving costs down from as much as $15,000 per year in 2000 to as little as $200 per year currently, making it possible to treat millions of low-income people. The innovative combination of up to three of the most effective ARV drugs into a single tablet by Indian generics manufacturers also cut costs and made staying on treatment much easier for patients.

Because India, Thailand and some other countries were not yet signatories to the new, more restrictive intellectual property rules adopted by the World Trade Organization (WTO) in 1995, they were free to manufacture and market generic ARVs in African and other poor countries. In recent years, however, the main exporters of generics have adopted WTO controls, jeopardizing future supplies of the low-cost anti-AIDS drugs on which treatment-as-prevention programmes will rely.

Africa led a successful fight at the WTO for an exemption for the export of generic drugs in 2003. But since then just one shipment of drugs has been made under its complicated procedures, a track record that has all but dashed hopes that the exemption would serve as a pharmaceutical lifeline to African and other poor countries (see Africa Renewal, April 2010). Michelle Childs, policy director for Doctors Without Borders' drug access programme, also accused the US and the European Union of seeking tougher patent protections than required by the WTO in bilateral trade negotiations with developing countries. Such actions, she told Africa Renewal, further undermine access to medicines by the global poor.

Despite the remaining obstacles, UNAIDS head Sidibé is optimistic that Africa is turning the corner on HIV/AIDS and that resources for the continent's other urgent health needs will be found. "You cannot deal with maternal health and child health and maternal mortality in Africa and not deal with HIV," he told Africa Renewal. "You cannot deal with tuberculosis if you cannot deal with HIV and vice versa. So this means that AIDS can be used to leverage progress in other areas. It is time to take AIDS out of this mode of crisis management and look at it as a long-term response."        

Primary school enrolment in sub-Saharan Africa