Lars O. Kalllingsa, IAS Permanent Secretariat, PO Box 5619, SE-11486 Stockholm, Sweden and Stefano Vella b, Istituto Superiore di Sanita, Viale Regina Elena 299, 00161 Rome, Italy.
Correspondence to: Stefano Vella MD President, International AIDS Society, c/o Istituto Superiore di Sanità, Viale Regina Elena 299 - 00161 - Rome - Italy, Phone: +39 06 49387214 Fax: +39 06 49903229, E-mail: firstname.lastname@example.org
It is estimated that about 60 million people have been infected with HIV since the beginning of the epidemic, 22 million of them have already died of AIDS. Every year five million people more become infected and three million more die of AIDS. In sub-Saharan Africa, which is disproportionately affected by HIV/AIDS, about one third of the adult population is HIV infected in many countries. AIDS is the most common cause of death in young adults, far ahead of malaria and tuberculosis – the other main killers of young people. In many countries this spreading epidemic is leading to national catastrophes with breakdown of infrastructures, economies, and national and regional securities. HIV infection is threatening the entire societal fabric and is reminiscent of the effects of the Black Plague.
The scale of the catastrophe has only recently been realized, and failure to mount sufficient response is shared by leaders of rich and poor nations alike.
The World AIDS Conference that was brought by the International AIDS Society (IAS) to South Africa last year, with its so called ‘‘Durban effect’’ helped to spread global awareness of the magnitude of resources needed to respond to this catastrophe. It has been calculated that about 10 billion US dollars per year are needed. Though the sum may sound high, its not insurmountable in a global context if we compare it with what the North of the world spend each year on trivial matters.
Linking prevention to care
A reason why the HIV/AIDS epidemic has been allowed to continue unabated in so many countries for years, is the lack of understanding that prevention needs to be linked with care, and the dogmatic unwillingness to commit resources for treatment. In the meantime the health infrastructure has been allowed to collapse in the countries worst hit. This lack of functioning of health care systems is now a major obstacle to the provision of care, should antiretroviral drugs be made available at affordable prices. In particular, there has been a lack of resources for testing and counselling. Ninety-five per cent of all people living with HIV in the world do not know that they are infected and are continuing to transmit HIV unknowingly to their sexual partners and to their offspring.
Early detection of HIV infection is vital in controlling further spread. The availability of treatment will act as an incentive for people to seek counselling and modify their behaviour. Studies have shown that people who know that they are HIV positive are more likely than HIV negative people to change their behaviour, and this change might be intensified if they know that adequate care would also be provided. Treatment will benefit the individual, and may also decrease the spread of HIV by diminishing its infectivity.
Access to Antiretroviral Drugs
On a global scale, the recent impressive therapeutic gains have only benefited 10% of those infected. The dramatic inequalities between rich and poor nations in caring for persons living with HIV/AIDS highlight the moral imperative to develop strategies to increase access to life-saving treatments for the majority of infected people.
The attention of many people is mainly focused on prices of antiretroviral drugs, because they indeed represent a major factor for the lack of access to therapy. Unfortunately, prices are set according to market conditions and the ability of the North of the world to pay, and not merely based on actual costs.
Too many years of protection on products and processes has forced many countries with limited resources and inability to pay to take advantage of compulsory licensing and of the manufacture or importation of generic drugs. These steps have revealed the real production costs of antiretrovirals, which may possibly reach about 200 US$ per year per patient for a standard ‘‘triple’’ combination and have increased the pressure on patent holders to reduce prices. Considering the speed with which HIV is spreading and the dimension of the AIDS catastrophe, starting legal actions against governments in the South is definitely not the way forward. Medicines for the South must not be constrained by the tight boundaries of a market transaction. The results of the North scientific endeavour must be translated into a benefit for those affected in developing countries.
However, a reliance on generics and local manufacturing will not completely address the issue. Local manufacturing will not be available to all countries, and generic producers will, very probably, not be able to produce the more sophisticated, safe and effective drugs.
We believe that the reasonable way forward is by establishing a well regulated differential pricing. In the long run, it will be more effective because all drugs will be needed, not only generics or the few locally produced.
HIV/AIDS is still an incurable infection. Because we depend on the pharmaceutical industry for their continued research investements, we cannot disregard intellectual property rights. Ways need to be found for the industry to recoup their investments in the North of the World, whilst selling antiretrovirals to the South at marginal costs.
The North has to accept this financial burden and sustain it for years. Governments of the South should use their limited funds, for other simple, but essential, health interventions that can also save years of healthy lives such as the provision of clean water and childhood immunisation programs.
Provision of drugs alone will not solve the crisis
It is a serious mistake to think that provision of the drugs alone will solve the crisis, and that all we need is enough money. Even with radical price reductions, millions of poor people will still lack access to HIV treatment. Simply providing cheap drugs will only meet the needs of a fortunate few with access to public health services. If the rich western countries had the same prevalence rates as some African countries, their public health resources would also be severely overburdened, by having to cope with millions of seriously ill patients.
It has been calculated that for each dollar used for antiretrovirals, three more are needed for an adequate health services infrastructure. Provision of antiretrovirals needs to be accompanied by resources for counselling and testing, drug distribution, education and training of health care providers, development of treatment protocols, and monitoring. In summary, it would require strengthening of the local health care infrastructure, which subsequently could have a major positive impact on other diseases affecting these countries. Very inexpensive drug interventions to decrease mother-to-child transmission have still not been implemented in the majority of African countries because of the lack of functioning infrastructures in addition to political complacency.
Science should play an increasing role in re-orienting research towards the particular needs of the South. Particularly through developing new drugs, microbicides and vaccines. However, there is also an urgent need to explore alternative strategies such as immune interventions, pulsed or intermittent treatments, and easier monitoring systems. Through the Clinical Trials Partnership, IAS is assisting key groups around the world to implement ethical standards and to perform clinical trials appropriate to developing countries.
The risk of spreading HIV-1 resistance to antiretrovirals has also been raised by some as an excuse to delay the implementation of life saving antiretroviral therapy programs in the developing world. The increased transmission of drug resistant viruses and an increased prevalence of these variants in newly infected patients are a serious public health concerns. The world-wide emergence of multidrug resistant tuberculosis should serve as a warning that drug resistant HIV can still become a much wider problem if its not monitored appropriately. Our collaboration with the WHO will build a program for the Global Monitoring of HIV resistance to antiretroviral drugs.
Antiretroviral treatment guidelines for resource-limited settings should be in place before even considering the provision of antiretrovirals, as well as programs to inform and educate health care providers. A mistake that has been made in the past was to simply deliver drugs to countries without preparing the health care workers to know how to use them safely and effectively. The IAS educational program (Share) works with local IAS members and public health officials throughout the developing world to run HIV/AIDS educational programs which are tailored to local needs.
Finally, it seems obvious that current international efforts have not been successful. Since 1950 we have seen a more than tenfold increase in international trade and the world economic growth multipy five times. During the same period we have also seen the most shocking and dramatic growth of poverty. We need to acknowledge that AIDS is unveiling the unsuccessful attempts of the North to foster the global development on an equitable basis. Clearly, there are no easy solutions. But, in the long run, we will not be able to move forward without a serious reconsideration of our current efforts in supporting African and other countries heavily affected by HIV to deal with and move beyond this epidemic.