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Our recent visit to HIV/AIDS hospital units in Phnom Penh, Cambodia, sharply delineated the contrasting capacity to respond to HIV/AIDS
in First World countries, such as Australia, and resource-poor
countries. Common to both settings is the relatively young age of
those affected, the close attention of loved ones and the dedication
of healthcare workers. The contrasts lie in the enormous gaps in
quality of healthcare facilities and access to effective HIV
treatments. HIV/AIDS may be only one of several major public health
issues for these countries, but, probably more than any other issue,
it highlights global resource inequities.
Over the past decade, Australia has been at the forefront of advances
in HIV treatment,1-4 which have provided
optimism for many people living with HIV/AIDS. Combination
antiretroviral therapy is one of the most cost-effective therapies
for a chronic disease in the developed world,5 and most First World
countries provide ready access to combination antiretroviral
therapy through publicly funded programs. However, 90% of the
estimated 36 million people living with HIV/AIDS are in
resource-poor countries,6 where access to new HIV
treatments is extremely limited: an estimated 0.5% of the global
market for antiretroviral therapy is sold in the poorest third of the
world.7
Indeed, most people with HIV in resource-poor countries experience inexorable decline in immune function leading
to death, just as people in First World countries did before the
mid-1990s. If the challenge of the past decade was to develop
therapeutic agents to control HIV infection, then the even greater
challenge of the current decade is to provide access to effective HIV
treatments for people in resource-poor countries. The political
commitment to achieve this is growing. Earlier this year, a
Declaration of Commitment was signed at the United Nations General
Assembly Special Session (UNGASS) on HIV/AIDS in New York. This
Declaration recognised that "access to medication in the context of
pandemics such as HIV/AIDS is one of the fundamental elements to
achieve progressively the full realisation of the right of everyone
to the enjoyment of the highest attainable standard of physical and
mental health".8
The Declaration also set a resource target of US$7-$10 billion per
year for HIV/AIDS prevention, care and support initiatives, to be
reached by 2005.8 However, expanding access
to effective HIV treatments also depends on other factors.
Affordability of antiretroviral therapy: Recent
endeavours to reduce the price of antiretroviral therapy for
resource-poor countries need to be continued. Affordability can be
improved through tiered pricing systems (maintaining current
pricing levels in industrialised countries to subsidise lower
pricing in resource-poor countries), further development of
generic production, and use of compulsory licences and other health
safeguards of the Agreement on Trade-Related Aspects of
Intellectual Property Rights from the World Trade
Organization.7 Within these measures,
pharmaceutical industry profitability needs to be maintained at
reasonable levels to enable continued research and development.
Current pricing of some triple combination regimens should make
potent antiretroviral therapy cost-effective for many
middle-income countries. For example,
stavudine-lamivudine-nevirapine, as produced by Cipla, an
Indian-based generic producer, sells for A$700 per year, or about 5%
of standard pharmaceutical industry pricing. In Brazil, a generic
drug program established by the government was followed by 80% price
reductions for several component agents of antiretroviral
therapy,9 enabling universal access
to antiretroviral therapy.
Although encouraging, these price reductions are not enough for most
resource-poor countries, where annual health budgets are often less
than $20 per capita.7 Further, while
implementation of antiretroviral therapy is being scaled up, it is
realistic to expect that only a minority of people living with
HIV/AIDS can be treated. This will necessitate difficult decisions
about selecting patients for antiretroviral therapy, which might
take into account social criteria (eg, family support and employment
status) in addition to biological criteria (eg, symptomatic
patients only to be treated).
Therapy delivery and monitoring: Simply making
antiretroviral therapy "available" is not the whole solution and may
be counterproductive.10 Inappropriate
antiretroviral therapy use may lead to viral resistance and
considerable drug toxicity. Healthcare systems must therefore be
developed to deliver and monitor HIV treatments effectively.
However, implementation of antiretroviral therapy programs cannot
wait for the optimal conditions that exist in industrialised
countries. Therapy programs and infrastructure should be scaled up
concurrently. Education and training of healthcare workers in
antiretroviral therapy and more broadly in clinical management of
HIV/AIDS will also be required.
Antiretroviral therapy needs to be provided within an integrated
system of HIV/AIDS treatment, care and support services. This may be
helped by closer collaboration between HIV/AIDS and tuberculosis
programs, which have been proposed as a platform for antiretroviral
therapy implementation.11 Tuberculosis programs
are the clinical entry point for many people with HIV/AIDS, as
tuberculosis is the most common AIDS-related illness in
resource-poor countries,12 and also have experience
in delivering combination pharmacotherapy in resource-poor
settings. Establishing referral networks between hospital-based
and home- and community-based HIV/AIDS care programs will also
improve delivery of a comprehensive package of treatment, care and
support.
Earlier diagnosis: In resource-poor countries,
people with HIV/AIDS generally present with very advanced
AIDS-related illness or die before presentation. Although
antiretroviral therapy is still effective when commenced late in HIV
disease, earlier HIV diagnosis would allow HIV preventive education
and other HIV treatments, such as prophylaxis against common
opportunistic infections, to be delivered. To achieve earlier
diagnosis, rapid scale-up of voluntary HIV counselling and testing
services is needed, including routine offering of HIV testing in
antenatal clinics in settings with relatively high HIV prevalence.
The latter would provide the foundations for preventing
mother-to-child transmission and introducing treatment and care
strategies, including antiretroviral therapy, earlier to many
women with HIV/AIDS.
Research on implementing antiretroviral therapy:
Priorities should include evaluating pilot antiretroviral therapy
programs in resource-poor settings, searching for more
cost-effective means of monitoring therapy, and developing simpler
therapeutic regimens (preferably, once-daily dosing) to enhance
adherence. An example of Australia's contribution to the regional
HIV/AIDS response is the HIV Netherlands-Australia-Thailand
Collaboration, which has conducted HIV therapeutic research in
Thailand since 1996.12 Australia now has the
opportunity to contribute to HIV/AIDS research and care in countries
such as Cambodia, where the burden of HIV/AIDS is increasingly being
felt (Box).
HIV prevention: Finally, if the UNGASS commitment to
reverse the spread of HIV/AIDS by 20157 is to succeed, a heightened
response is required to HIV/AIDS prevention as well as care. Both arms
need increased priority and allocation of resources. They also need
close interlinking in a broadly based response at national and
community levels. However, implementing antiretroviral therapy
may enhance HIV prevention through increased incentive for HIV
testing accompanied by HIV preventive education.
If the HIV/AIDS treatment divide between industrialised and
resource-poor countries is to be bridged, we urgently need
Australian research, medical, and educational institutions to
become more involved, and public and private sector funding to be
enhanced.
Gregory J Dore
Senior Lecturer, National Centre in HIV Epidemiology and Clinical
Research
University of New South Wales; and Infectious Diseases
Physician
HIV/Immunology/Infectious Diseases Clinical Services
Unit
St Vincent's Hospital, Sydney, NSW
gdoreATnchecr.unsw.edu.au
David A Cooper
Professor, National Centre in HIV Epidemiology and Clinical
Research
University of New South Wales; and Director
HIV/Immunology/Infectious Diseases Clinical Services Unit
St
Vincent's Hospital, Sydney, NSW
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