HIV Care in 2003: A Viewpoint

The year 2002 held promise for expanding global access to HIV care and treatment, including antiretroviral therapy. This was particularly the case in developing countries. Most importantly, the Global Fund to Fight AIDS, Tuberculosis and Malaria began operation, following its founding in 2001. The World Health Organization (WHO) developed guidelines for the use of antiretroviral medications in developing countries.¹ In many places, the price of antiretroviral treatment has been markedly reduced, mainly through generic production. Several international organizations and projects came into existence or expanded their efforts in 2002, including the International Association of Physicians in AIDS Care (IAPAC), TREATAsia, PharmAccess, the MTCT-Plus Initiative of Columbia University, the International Treatment Access Coalition (ITAC) and many others. Yet there remains so much left to be accomplished, and the question remains, how can we build on this solid foundation to do a better job of fighting the pandemic worldwide?

The most important task is getting the message to policy makers of the need to fund HIV care. And by "policy makers," let me explain: I mean everyone from the leaders of United Nations agencies; to the U.S. President and Congress; to other heads of state and governments; to hospital directors, and department and division heads; all the way down to the financial decision makers in individual families. We must build on the successes of the last two years, during which many of the preliminary successes mentioned above could be attributed to educating decision makers on the importance of treatment. We must continue to help those who hold the purse strings to understand that HIV prevention and care are not mutually exclusive -- that, instead, these functions should be integrated, so that one can benefit the other. We must ensure that adequate funding is available for both prevention and care.

The Global Fund opens the door for antiretroviral therapy in resource-limited countries. In my opinion, too many countries still view the fund as a tool for funding education and prevention campaigns, and for treatment and prevention of opportunistic infections. These are functions that governments should be undertaking with their own resources. I am also concerned that too many countries expect the Global Fund to entirely underwrite programming. It would be better if the Global Fund required recipient countries to provide some level of matching funding, in order to ensure the country's commitment. The matching fund requirement could be scaled according to gross domestic product (GDP), or another appropriate indicator of national resources. Another necessary change would be to the restriction mandating that each country may only submit one proposal. This restriction gives individual ministries of health too much power of oversight, and prevents healthy competition that can cause the best potential grantees to rise to the surface.

Guidelines on the use of antiretroviral medications in resource-limited settings were developed in 2002. The emerging difference between antiretroviral treatment in the developed and developing worlds can be summarized as follows:

• when public funds are used to provide antiretroviral medications in the developing world, these medications are less likely to be offered to patients with CD4 counts between 200 and 350 cells/mm³;

• the use of monitoring tools (CD4, viral load, resistance testing) will be more restricted or discouraged in resource-limited settings; and

• some antiretrovirals may not be available in certain resource-limited settings due to licensing issues, the cost of the drugs, and the need for cold storage.

One apparent discrepancy is that cost is not usually listed among the top considerations in guidelines for developing world use of antiretroviral medications. But it is one of most important limiting factors. For example, abacavir is usually on the top of the recommended antiretroviral list, but its price prohibits its use in developing countries. We would be better off stating that all highly active regimens are, essentially, equally effective and allow physicians in the developing world to choose the cheapest regimen available. Evidence does exist that abacavir or nevirapine-containing regimens are as effective as protease inhibitors or efavirenz-containing regimens.^{2, 3}

The bottom line issue in antiretroviral treatment in developing countries is price reduction of medications and laboratory monitoring. Production and importation of good quality generic antiretroviral medications should not be discouraged because of the fear of trade sanctions or other international manipulations. As many older antiretroviral medications as possible should be made available for generic production. This will drive down the price of brand-name antiretroviral medications by virtue of free market competition. A multi-tier pricing policy should be adopted by all antiretroviral producers, generic and brand-name. Governments should give tax benefits to these companies. They should also undertake measures to prevent the smuggling of reduced-price antiretroviral medications into rich countries.

The training of physicians and other healthcare providers in antiretroviral use is also a necessary challenge, especially in the case of large-scale training in countries where rapid scale-up of antiretroviral therapy is planned. Local experts must be identified to carry out such nationwide training, and measures such as the Global AIDS Learning & Evaluation Network (GALEN) are good mechanisms by which to identify trainers within these networks. Training courses must have several levels and must be concise since medical personnel are usually very busy. Follow-up training, or continuing education, must be maintained. Training that will lead to attitude change and the sensitization of healthcare providers to patient concerns is of utmost importance as well, since skills necessary to assess and enhance treatment compliance among patients being treated with antiretroviral medications are critical to ensuring adherence and to preventing drug resistance.

To that end, HIV-infected individuals must be well informed and prepared for antiretroviral therapy. Balanced information must be provided with regard to all means of care, including alternate care options. The importance of adherence to prescribed antiretroviral medications should be regularly reiterated, with use of patient reference hand-outs where they are available. Working to eliminate the stigma associated with HIV, and the creation of peer support groups are other methods by which adherence can be improved.

In conclusion, we begin in 2003 on a good base for launching substantial antiretroviral therapy scale-up in many resource-limited countries. The mechanisms are there, even if they require some perfecting. The main ingredient of which we need a larger portion is the world's will to make further progress.

Praphan Phanuphak is Director of the Thai Red Cross AIDS Research Centre in Bangkok, Thailand, and serves on the Faculty of Medicine at Chulalongkorn University. He also serves on the Board of Trustees of the International Association of Physicians in AIDS Care (IAPAC).

References

1. World Health Organization. Scaling-up antiretroviral therapy in resource-limited settings: Guidelines for a public health approach. June 2002.

2. Staszewski S., Keiser P., Montaner J., et al. Abacavir-lamivudine-zidovudine vs. indinavir-lamivudine-zidovudine in antiretroviral-naive HIV-infected adults: A randomized equivalence trial. JAMA 2001; 285:1155-1163.

3. Van Leth F., Phanupahk P., Ruxrungtham K., et al. The 2NN Study: A randomised comparative trial of first-line antiretroviral therapy with regimens containing either nevirapine, efavirenz or both drugs combined, together with stavudine and lamivudine, submitted for publication.