Why Expanding Global HIV Treatment Access May Face an Uncertain Future

In this study summary, Alex Coutinho, M.D., of the Infectious Diseases Institute at Makerere University in Kampala, Uganda, discusses the limits and realities of antiretroviral treatment (ART) scale-up. After the discussion, Dr. Coutinho will answer questions.

Alex Coutinho: My talk is about the realities and the limits of ART scale-up as seen from the context of developing countries.¹

I'm going to acknowledge the good realities, the good things that have happened in the past five years, in particular, the unprecedented scale-up to reach 3 million people -- and the fact that, even in developing countries, people are adhering to drugs. We're getting good viral load suppression. We're also extending programs to mothers and children.

But I'm also going to touch on the aspects of the bad reality, the fact that there is a large percentage of people who start treatment who die, particularly early mortality and cumulative mortality of up to 20% -- and the fact that another 20% are often lost to follow-up.

Alex Coutinho, M.D.

I'm also going to talk about the fact that we have very poor coverage for testing and that despite the 3 million people in treatment, that only represents about 30% of those who should be in treatment. I will then touch on what I see as the current and future limitations to maintaining scale-up at an exponential scale, because we've moved from a couple hundred thousand to 3 million [receiving treatment] in the space of five years. That rate, in my view, is going to fall back -- and that's going to be influenced by four or five main factors.

The first is that the funding from the West, particularly PEPFAR [U.S. President's Emergency Plan for AIDS Relief] and the Global Fund [to Fight AIDS, Tuberculosis and Malaria], is not going to keep pace with the need for scaling up treatment. For instance, PEPFAR 2 is slotted to add an additional million people on treatment, but since it's already achieved 2 million in five years, and it's only going to add a million in the next five years, obviously the rate of increase is going to be much lower than it is now.

The same is true for the Global Fund. And yet, national resources for providing treatment are nowhere near compensating for the reduction in PEPFAR. People look at 15 billion [dollars] to 43 billion [dollars]: If you do the math, you'll realize that right now PEPFAR is operating at about 25 billion, because it's a 5 billion per year fund. So it's not actually a doubling or even a tripling of resources.

The other is the capacity within the recipient countries [and communities], particularly [in the area of] human resources. These 3 million [people on HIV treatment] that we have achieved have been largely low-hanging fruit, much easier to reach than the next 3 million, who are more likely to be further away from centers of excellence, are likely to be harder-to-reach populations, are likely to move on to second-line therapy, and so on and so forth. This is really the gist of what I'm going to speak about.

I will then talk about what are some of the things that we can do to try to maintain the current exponential scale-up of antiretroviral therapy whilst maintaining the quality that is required to see an impact on individuals from treatment. Thank you.

Reporter #1: I wonder if you could comment on the medications and regimens that are available in the developing world -- particularly those that would be considered inadequate or inferior in the developed world, such as stavudine [d4T, Zerit], and the impact that you might foresee in the next several years in its use.

Alex Coutinho: I think that we all recognize that the regimens that were used were driven primarily by the cost, but also those regimens that were in combination. There is much wider recognition that we need to abandon stavudine in particular. [This will, of course, influence the cost, but it also requires the development of new drugs formulated as a single pill, since simpler regimens result in better adherence.] But the price will go up and that will put even more pressure on the existing resources.

Reporter #2: What would be your analysis on the refusal of the Western world to increase funds to the fight against HIV and AIDS? Do you think the financial crisis has anything to do with that?

Alex Coutinho: Actually, it's not a refusal. Superficially, it appears as if, for instance, America has tripled the amount of money available -- this was before the economic crisis. But when you do the math and see how much money would actually be needed to double it, it's actually much more than the 43 billion. I think for the Global Fund, there has been an increase. Whether the economic crisis will impact the actual amount of money available to the Global Fund remains to be seen, so I don't think that it's necessarily a refusal. But the reality is that there is insufficient funding, and if the economic crisis continues, for the Global Fund, there may be reduced funding.

This transcript has been lightly edited for clarity.

Reference

1. Coutinho A. Limits and realities of ART scale-up. In: Program and abstracts of the 16th Conference on Retroviruses and Opportunistic Infections; February 8-11, 2009; Montréal, Canada. Abstract 12.
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