HIV/AIDS in Africa: treatment as a right and strategies for fair implementation. False assumptions on the basis of a minimalistic approach

Numerous articles, including that of Badri et al. ^[1] have reaffirmed the need to give priority in providing highly active antiretroviral therapy (HAART) in Africa to HIV-positive patients who are symptomatic. Those proposing this strategy believe that the normal diagnostic tests, such as the CD4 cell count and the viral load, standard in western countries, would become unnecessary in the African context, where immediate treatment must be initiated for patients who are in the life-threatening stages 3 or 4 of the disease. As the size of this late-stage population is already considerable, approximately 3 million people in Africa, the authors concluded that the best strategy for fighting AIDS is to give that population priority in treatment without using immunological and virological parameters as a reference or control during therapy.

This approach seems to offer an apparently reasonable solution by focusing on those individuals facing an immediate danger of death. Nevertheless, numerous doubts remain, not only about the real equity of such a choice, but also about its effectiveness.

The success of the therapy is related to the interaction of drugs and the immune system. The therapeutic response improves in conjunction with the conservation of the immune function. Therefore, the increase, both absolute and relative, in the CD4 cell count and the corresponding reduction of the viral load is markedly better in those patients who initiated HAART when their immune function was at least partly active. On the contrary, patients in an advanced stage of immune impairment do not respond as well to the therapy and present two phenomena. The mortality rate of the subgroup of patients who start treatment with CD4 cell counts less than 50 cells/mm³ and 51-200 cells/mm³ is 6.6 and 3.4-fold greater than in patients starting treatment with a CD4 cell count greater than 200 cells/mm^{3 [2]}. The risk of progression to AIDS and death was also higher in patients with greater than 100 000 HIV-RNA copies/ml ^[3]. The results presented by the DREAM Programme at the San Francisco Conference fully confirm these data also in Africa ^[4].

The probability of developing viral resistance in this subgroup is higher and, ipso facto, the need for close virological monitoring is highly recommended. On the basis of these considerations, one must highlight the substantially greater benefits associated with an initiation of therapy in accordance with international guidelines for the greatest possible number of patients.

Without doubt, the fight against HIV/AIDS must integrate strategies of treatment and prevention. By choosing to treat only symptomatic patients, the benefits in terms of prevention will be drastically reduced. Asymptomatic patients are those more involved in the transmission of the epidemic, for example through sexual intercourse. Therefore, treating patients on the basis of immune and virological eligibility criteria would lead to greater benefits in the area of prevention.

In more general terms, it could be said that the authors of the previously cited article move from the assumption that adequate economic resources for fighting AIDS in Africa do not exist. Although this was certainly true in the past, it is no longer the case. The recent mobilization of significant funds from various sources, as well as the increased availability of non-patented drugs at reduced prices, substantially modifies this assumption.

On the other hand, it is difficult to see how the minimalistic approach to antiviral therapy would be successful in the medium to long term, both in terms of pharmaceutical costs and clinical results.

The diffusion of antiretroviral agents according to western standards will generate new positive effects, such as a further decrease in the price of drugs, as well as the easily foreseen decrease in the price of diagnostics. The experience of DREAM in this setting is important, because the price of diagnostics and drugs has been carefully negotiated and then reduced.

In conclusion, taking shortcuts and settling for less than the gold standard and accepted guidelines in therapy and diagnostics will lead to real problems of fairness, reduced effectiveness in the areas of both treatment and prevention, and a greater than expected increase in resistance. Treating as many patients as possible, as long as they are eligible for HAART, and treating them well would seem to be the wisest and even the most cost-effective choice at present.

The right to treatment is a basic human right, as affirmed in the Protocol of Rome, signed by 13 African ministers of health at the headquarters of the Sant'Egidio in May 2004 ^[5]. This right must not be discounted or subjected to half measures. If we do not recognize this right fully, we will end up by rejecting it de facto.