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Introduction

Until recently, help for low-income countries focused on the provision of food and water supplies. Charities and NGOs concentrated their efforts on fighting poverty, famine and drought in Africa, and some lesser attempts were made to combat diseases such as TB and measles. It is only recently that people have started to become aware of the fact that HIV/AIDS is a problem of equal or greater gravity.

It was almost accepted that people in developing countries who were infected with HIV would die, and that the problems of poverty, food and water supplies were so pressing that disease wasn't a consideration. This was especially true in areas such as sub-Saharan Africa, where both HIV and poverty were vital issues.

Eventually, when discussion started about HIV issues in the late 90s, people started to ask why there were so many deaths occurring when the drugs existed that could prevent them, and why these drugs - known as antiretrovirals - were so very expensive. People in resource poor countries began demanding access to the medication that could save their lives.

By 2003, pilot projects such as those run by Médecins Sans Frontières had demonstrated that antiretroviral treatment programmes were feasible even in the poorest parts of the world. People were able to adhere to the treatment and the benefits were similar to those seen for people in Western countries.

Opinion has now shifted and providing anti-AIDS medication has become a much higher priority for governments, employers and NGOs around the world. Specific targets have been set for rapidly increasing treatment access in resource-poor countries, and much more money is being provided. At the UN World Summit in 2005, the world's leaders pledged they would try to achieve universal access to treatment by 2010.

The recent change in attitude offers hope to millions of people living with HIV around the world. However, as of December 2007, only 2.99 million people living with HIV in resource-poor countries were receiving antiretroviral treatment, out of 9.7 million in need.¹ The most difficult stages of scaling up treatment access are only just beginning, and there remain many challenges to overcome. This page looks at some of the most critical issues involved in providing HIV/AIDS treatment to millions of people.

Where is the money coming from?

The price of antiretroviral medication in resource-poor countries has plummeted in recent years. A year’s course of drugs for first-line treatment that once cost several thousand dollars can now be bought for a few hundred dollars at most, and in some places for as little as $92.²

One reason for the price cuts is greater competition between pharmaceutical companies, which has been fuelled by the growth of generic drug production. A generic drug is a copy of a brand name drug made by another company. Generic drugs are just as effective as brand name versions but they are often less expensive. Because the need for treatment is so urgent, rules have been relaxed to allow generic drug distribution in some of the poorer parts of the world. The Clinton Foundation has led many of the recent negotiations on price reductions.

The full cost of providing treatment – including salaries, infrastructure and other services – is well beyond the means of many public health systems.

But despite such progress, the cost of drugs remains an important issue. For example, nearly two-thirds of adults receiving antiretroviral therapy in low- and middle-income countries are taking a drug called d4T as part of their combination therapy. This medicine is no longer recommended for use in Europe and North America because of its side effects. The main reason for the continued use of d4T in the developing world is that it is much cheaper than the alternatives. Second-line regimens (for patients who have to switch treatments) still cost more than one thousand dollars per patient per year. In the near future, as more people change to second-line regimens because of side effects or drug resistance, the need for further price reductions will intensify.

Besides the drugs themselves, there are many other costs in providing treatment, such as salaries, clinic overheads and supply chains. The full expense is well beyond the means of many public health systems. This is why foreign donors are needed.

Major donors include the Global Fund for AIDS, TB and Malaria, the US President’s Emergency Fund for AIDS Relief (PEPFAR), other developed-country governments, the World Bank and various non-governmental organisations. These donors add to the money and resources provided by the affected countries. (Read more about funding the fight against AIDS.)

It is important that the cost of treatment is fully covered so that users don’t have to pay fees, either for the drugs themselves or for associated clinical tests. Researchers have found that even relatively small user fees inhibit treatment access and undermine health benefits.^{3 4} For example, a study in Nigeria found that 44% of patients took their drugs intermittently or in insufficient dosages because they could not afford to pay fees of up to $67 per month.⁵ Such conditions greatly increase the risk of HIV developing drug resistance. Collecting money from patients requires bureaucracy and generates relatively little revenue.

Despite recent increases, funding from international donors remains insufficient. But this is far from the only problem involved in scaling up treatment access.

Critical issues for treatment programmes

Treatment programmes have to overcome many obstacles, ranging from patient recruitment to procuring drugs. The following are some of the most significant issues.

Counselling, testing, and treatment awareness

HIV counselling and testing is particularly important as a starting point for access to other HIV/AIDS-related services. If a person does not know they are infected, they cannot get any treatment or care. In too many cases people are diagnosed HIV positive when they are already seriously ill. At this point, there are fewer opportunities for cost-effective interventions.

In addition to providing enough HIV counselling and testing facilities to meet demand, it is important to encourage people to use these services. Raising awareness of the benefits of treatment provides people with an incentive to learn their HIV status, and so should help to increase demand. However, in many societies fear of stigma and discrimination remains a serious barrier to testing. To help overcome this problem, many countries are moving towards offering every patient an HIV test as a routine part of health care, regardless of symptoms.

Helping people to meet programme requirements

Patient selection criteria are used to determine who is most likely to benefit from antiretroviral treatment. Usually the patient must demonstrate that they are able to attend the treatment centre regularly and to adhere to daily medication. It may be necessary, for example, to arrange transport to help people meet these requirements. Also, the treatment programme may need to help people to find the support they need to cope with the demands of treatment, whether it be from friends, family or support groups. Those who have alcohol or other drug addictions, or depression, need to be helped to overcome their problems before they start treatment.

Nutrition

In the absence of treatment, someone who has HIV is likely to remain healthy for longer if they have an ample and nutritious diet. The need for good nutrition also applies to those who are receiving treatment, especially because some of the drugs should be taken on a full stomach, and little is known about the effects of antiretrovirals on malnourished people. One study in Singapore found that malnourished people were less likely than others to benefit from the medication.⁶ Researchers in Malawi found that severely malnourished patients were six times more likely to die in the first three months of treatment than those with a normal nutritional status.⁷

Furthermore, if someone lacks an adequate food supply then they are less likely to be able to adhere to a daily treatment regimen. Hunger is a much more immediate problem than the threat of AIDS, and desperate people may even resort to selling their drugs to feed themselves and their families. For all of these reasons, nutritional support should be a key component of AIDS treatment programmes.

Treatment for other infections

By the time someone reaches the stage of HIV infection at which treatment is required, they are often suffering from opportunistic infections such as tuberculosis and candidiasis. Treatment centres must be able to provide medication for these infections as well as the underlying HIV infection. They must also make patients aware of possible harmful interactions between antiretrovirals and other pharmaceutical drugs and alternative therapies. For example, some substances can lower the rate at which antiretroviral chemicals are absorbed by the body, and so reduce their effectiveness. Conversely, the antiretroviral efavirenz can reduce concentrations of the tuberculosis drug rifabutin, which means the dose of rifabutin may need to be increased.⁸

Infrastructure

Treatment centres need consulting rooms, offices, waiting rooms and secure storage for valuable drugs. They also require basic facilities to test for anaemia, pregnancy, renal function, white blood cell counts and other factors that may affect treatment.

In developed countries, decisions about when to start treatment are based on the results of clinical tests called the CD4 test and the viral load test. Ideally these tests should be used everywhere, but in many parts of the world they are currently unavailable, as they require expensive equipment, electricity and trained technicians. In theory, decisions about when to start treatment may be based on symptoms alone. However in practice some treatment programmes provide medication only to people who have had a CD4 count.

Reliable supply chains

Antiretroviral drugs can stop working if they are not taken every single day. It is therefore essential to maintain an uninterrupted supply of medication, from the factories where the drugs are made all the way down to the rural villages where they are needed. This presents difficulties because in many countries the distribution systems for all kinds of medicines are chronically weak and unreliable. Transport and communication networks are often in very poor condition.

Initiatives trying to remedy this situation include the AIDS Medicines and Diagnostics Service (AMDS), whose partners include UN agencies, USAID, the Clinton Foundation and various other non-governmental organisations. AMDS collects and distributes information about drug pricing and supply chains, as well as providing technical assistance to supply chain managers.

In September 2005, PEPFAR awarded a contract for supply chain management to a consortium led by John Snow International and Management Sciences for Health. Their system is intended to handle a wide range of HIV/AIDS related products, including drugs and laboratory equipment, for US-funded projects around the world. Several members of the PEPFAR supply chain consortium also participate in the AMDS.

Trained staff

The parts of the world worst affected by AIDS have a dire shortage of health workers. In particular Africa, which is home to 14% of the world’s population, and carries 25% of the global disease burden, has only 1.3% of global health workers. This shortage is one of the most serious problems facing antiretroviral treatment programmes.

One reason for the paucity of health workers in poor countries is the international poaching of doctors and nurses by Europe and North America. Skilled professionals are lured abroad by better working conditions and much better pay. This migration satisfies the needs of the rich countries, but drains resources from nations that can ill afford to lose the workers they have spent so much money training. Rates of health worker migration range from 8% to as high as 60% in some African countries.⁹

AIDS also contributes to the shortage of health workers. In the worst affected countries, doctors and nurses are dying of AIDS at such a fast rate that training colleges struggle to produce enough replacements. Botswana lost approximately 17% of its health-care workforce due to AIDS between 1999 and 2005.¹⁰

In response, many countries are working hard to expand recruitment and training schemes. Some have also sought to ease the shortage of health workers by recruiting doctors and nurses from abroad, against the usual flow of worker migration. Difficulties can however arise if the foreign workers are unable to speak local languages, or are unused to the local way of life.

An increasingly popular alternative is to move many of the routine tasks of AIDS care from more specialised to less specialised staff. Doctors can ease their workload by transferring duties to non-physician clinicians; clinicians can shift tasks to nurses or midwives; and the less technical jobs can be handed over to counsellors or community health workers. With sufficient organisation, one treatment specialist can oversee thousands of doctors, who in turn can supervise tens of thousands of clinical officers, nurses, community health workers and informal assistants. This "task shifting" approach has proven successful in a number of countries including Botswana and Mozambique.^11 12 However, it has been argued that 'task-shifting' should only be considered only as part of an overall strategy when attempting to address the human resources shortages. ¹³

In May 2006 the international community responded to the health worker crisis by collectively creating the Global Health Workforce Alliance (GHWA). Under the alliance, task forces and working groups were established in order to address specific issues such as technical cooperation, migration and resource mobilisation. ¹⁴ One such group, the Task Force for Scaling up Education and Training for Health Workers, aims to encourage governments and donors to invest in the education and training of health workers in resource-poor countries. ¹⁵

Moving towards universal access

It is relatively easy to provide treatment where there is good infrastructure and AIDS-related activities are already taking place, such as in antenatal clinics. It is much harder to move into rural areas and reach people who have little or no contact with health services or community organisations, or to reach marginalised groups such as refugees, prisoners and injecting drug users. Treatment providers need to look for innovative ways to reach the most underserved population groups as they strive for universal access. One example is the use of mobile outreach services to take drugs from treatment centres to outlying communities on a regular basis.¹⁶

Another underserved population in many cases is children. It is more difficult to treat HIV-positive children because dosages depend on size and weight, so standard pills and capsules are often unsuitable. The best solution may be to provide antiretroviral syrups, but these can be awkward to procure, transport and store (some may require refrigeration). Children often have difficulty coping with swallowing large pills or unpleasant tasting syrups, as well as coping with side effects, and adult supervision may be needed to ensure adherence. (Read more about providing treatment for children.)

Changing mindsets

For many years, the assistance provided to people living with HIV in poor countries has largely consisted of home-based palliative care and helping people to prepare for death, and some support organisations still regard this as the only help they can give. There is therefore a real need to change attitudes – to let people know that, with sufficient effort, treatment can be provided to save lives even in the least developed places on earth.

The way forward

Access to antiretroviral treatment has more than tripled since the end of 2003, and a few countries such as Brazil and Botswana have already raised coverage to over 80%, saving tens of thousands of lives. Although there are many challenges involved in providing treatment to millions, none of these is insolvable.

If enough effort and resources are invested now, the future for millions of people around the world could be a great deal brighter.

The most effective treatment programmes are those that are truly community-led. Governments, health providers and non-governmental organisations should strive to mobilise all sectors of society to achieve the fastest possible rate of expansion. This means harnessing the united strengths of community organisations, faith-based groups, employers, families and people living with HIV themselves.

If enough effort and resources are invested now, the future for millions of people around the world could be a great deal brighter.

"This is the first time that complex therapy for a chronic condition has been introduced at anything approaching this scale in the developing world. The challenges in providing sustainable care in resource-poor settings are enormous, as we expected them to be. But every day demonstrates that this type of care can and must be provided." - Dr Lee Jong-wook, Director General of the World Health Organisation.¹⁷

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