November 27, 2006— From its first two documented deaths in California in mid-1981, AIDS has marched relentlessly across countries and continents, scything down more than 25 million people along the way, and ushering in one of the gravest development threats of our time.
According to the latest figures from UNAIDS, there are now over 38 million people living with HIV worldwide. Four million people are newly infected each year, and AIDS is increasingly a disease of young women, who have few means to protect themselves and now account for a majority of new infections in many countries.
The new update from UNAIDS, however, also shows some long-overdue progress on treatment.
People’s access to life-saving anti-retroviral (ARV) drugs has expanded significantly, from 240,000 people in 2001 to 1.6 million people in low- and middle-income countries in 2006.
Despite problems with health infrastructure, and shortages of trained medical workers, sub-Saharan Africa is now treating more than a million people living with AIDS, a 10 fold increase since late 2003. ARV prices have dropped significantly and procurement systems have improved, as has generic drug availability.
Still, HIV treatment coverage varies considerably within regions. In sub-Saharan Africa, treatment coverage of those in need ranges from 3 percent in the Central African Republic, to 85 percent in Botswana.
World AIDS Day on December 1 will underscore the continuing urgency in bringing effective HIV prevention and treatment strategies to communities the world over, as will a global conference at the Bank this week called "Sustaining Treatment Costs - Who will Pay?", which brings together many of the world’s leading authorities on AIDS treatment. The summit is co-sponsored by WHO, UNAIDS, and the World Bank, and will be opened by World Bank President Paul Wolfowitz.
“Putting people on life-saving AIDS treatment is a commitment that can span decades,” says Dr.Debrework Zewdie, Director of the World Bank’s Global HIV and AIDS Program, and the host of the treatment conference that begins this morning.
“So we can’t have the ‘here today-gone tomorrow’ problem where governments and donors put people on treatment, and then walk away from them a couple of years later and say ‘we haven’t got the money to keep this program going.’ That prospect worries me greatly.”
"Putting people on life-saving AIDS treatment is a commitment that can span decades,” says Dr.Debrework Zewdie, Director of the World Bank’s Global HIV and AIDS Program.
Zewdie says the issue of predictable financing becomes even more acute as some people on existing ‘first-line’ AIDS drugs develop HIV which is resistant to the medicine, and then need to be switched to ‘second-line’ therapy to stay alive. Currently second line drugs are considerably more expensive than first line, and the decision to switch patients from first to second line treatment also requires special blood tests which can be extremely expensive.
These costs have critical implications for the sustainability of treatment since in many developing countries, per capita health spending is less than $10 a year. Consequently, the ability of poor and middle-income countries to afford antiretroviral treatment programs for people with AIDS will depend very directly on preventing new infections.
Children account for approximately 14 percent of AIDS deaths but for only about 6 percent of recipients of antiretroviral therapy in low- and middle-income countries.
The fact that even 1.6 million people living with AIDS are still alive, thanks to treatment, is something of a triumph after years of assuming that poor countries could never muster the medical expertise and money needed to make ARV possible. But as countries like Thailand, and Brazil have shown, universal access to treatment is possible.
For example, since 1996, Brazil’s treatment efforts have helped the country to prevent more than 60,000 new cases of AIDS and 90,000 HIV-related deaths. As of May this year, Thailand was treating roughly 78,000 AIDS patients, more than 90 percent of those in need of treatment.
According to a recent Bank report, The Economics of Effective AIDS Treatment: Evaluating Policy Options for Thailand, the country's ability to provide ART affordably to more than 80,000 Thais with AIDS is the result of highly effective prevention campaigns over previous years, a vast network of district level hospitals and rural health clinics with the capacity to provide widespread treatment, a strong community of non-governmental organizations that has worked closely with government on rolling out the expanded ARV program, and the close involvement of people living with HIV/AIDS themselves.
"Thailand's ART program is a useful beacon for other developing countries which are looking at how to provide this treatment to people with advanced HIV," says Ana Revenga, co-author of the Thailand report and a World Bank Lead Economist in its East Asia and the Pacific department who will present her work at this week’s conference.
With more than 20 low and middle income countries now treating more than 50 percent of their citizens in need, the notion that AIDS treatment is only the preserve of Organisation for Economic Co-operation and Development (OECD) countries has finally been banished. Nonetheless, there are real problems that have to be resolved before more countries embark on treatment programs for people living with AIDS.
Countries and donors need to show continual results if AIDS is to keep the public’s attention as a top priority for action at global and national levels.
Kevin De Cock, Director of the World Health Organization’s HIV/AIDS department, who is co-sponsoring the meeting at the Bank this week, believes that the biggest roadblock to expanding universal treatment services is “the frailty of health systems - including human resources, physical infrastructure, laboratory capacity, procurement and supply systems, fiscal management, and the whole clinical and public health complex required to manage and deliver services.”
De Cock will also emphasize the need to treat an estimated 800,000 children under 15 years of age who are living with AIDS, most of them in Africa. Children account for approximately 14 percent of AIDS deaths but for only about 6 percent of recipients of antiretroviral therapy in low- and middle income countries, and “we must conclude that treatment scale-up has so far left children behind.”
The third co-sponsor of this week’s treatment conference is the Executive Director of UNAIDS, Peter Piot, who writing in The Lancet recently, stressed the need for countries and donors to show continual results if AIDS is to keep the public’s attention as a top priority for action at global and national levels.
“Because the span of public and political attention is generally short, irrespective of the merits of the issue, keeping AIDS high on public agendas over the long term is a matter that warrants the closest attention…to maintain the AIDS response as a priority we need to show continual results on the ground—i.e., that the major investments made in fighting AIDS are having a commensurate effect in terms of averted infections, illness, and deaths.”