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November 28, 2006—When the World Bank and its partners teamed up for a pilot program to help learn about what it would take to scale up comprehensive HIV/AIDS services in three African countries, they thought their biggest challenge might be making sure patients successfully followed their complex drug regimens.
But in practice, “the technical issues have not proven to be as big as we thought they would be,” says Albertus Voetberg, leader of the World Bank team involved in the 2-year-old Treatment Acceleration Project (TAP) in Mozambique, Burkina Faso and Ghana.
More worrisome are the uncertainties, says Voetberg—such as how to fund AIDS treatment, including new antiretroviral therapy, that could continue for more than 20 years per patient in cash-strapped African nations. Facing unpredictable increases in cost, regardless of timeframe, can be daunting..
“Once you start somebody on treatment, you have a moral or ethical obligation to continue. You cannot say well, sorry, the funds are finished, you die tomorrow. It's just impossible,” says Voetberg.
Voetberg is a participant in a high-level AIDS conference, Sustaining Treatment Costs - Who will Pay? hosted by the World Bank, World Health Organization (WHO), and UNAIDS this week that looks at the issue of how more people who need antiretroviral treatment can get access to it, and how such treatment should be funded.
Some 4.6 million Africans have HIV infection serious enough to need life-prolonging ARV drugs—but only about a million people are getting them, according to UNAIDS.
The Bank, WHO and the United Nations Economic Commission for Africa (UNECA) launched TAP in 2004 to look for the best ways to provide and monitor AIDS treatment, with an eye toward scaling up the capacity of health systems to deal with the problem and incorporating lessons learned into existing and future AIDS programs, says Voetberg.
TAP is funded by a grant of US$59.8 million from the International Development Association (IDA), the part of the World Bank that helps the earth's poorest countries reduce poverty by providing interest-free loans and grants for programs aimed at boosting economic growth and improving living conditions.
So far, over 90 percent of about 15,000 patients in the three countries have been able to adhere to their drug regimens with the help of highly motivated support groups, says Cassandra de Souza, TAP's point person at the Bank's headquarters in Washington, DC.
And while de Souza cautions it may be too early in TAP's research to get a full picture of drug resistance among AIDS patients, so far there has not been as much need as expected for the more expensive second-line drug treatment.
In Mozambique, for instance, the failure rate of first-line ARV treatment is 3.5 percent a year, “which is quite low,” says Dr. Leonardo Palombi of Drug Resources Enhancement against AIDS and Malnutrition (DREAM), a non-governmental organization participating in TAP that was created by the Christian organization Community of Sant 'Egidio.
DREAM, which began offering free Highly Active Anti-Retroviral Therapy (HAART) to Mozambique patients in 2002, is one of three NGOs participating in Mozambique's TAP program.
The group delivers ARV to 20,000 patients. It has trained 1,000 health professionals and built specialized molecular biology laboratories for tests that aid in monitoring AIDS patients.
Palombi expects TAP data to help reveal the rate at which people will need second, third, or even fourth-line ARV treatment, and so aid in forecasting the needs of future cohorts of AIDS patients.
Unlike the other TAP countries, Ghana and Burkina Faso, where the epidemic is leveling off, Mozambique is “now following the trend of South Africa” and is in what could be defined as an “explosive epidemic time,” Palombi says.
“The greatest challenge now is to scale up to a much greater proportion, because unfortunately, Mozambique has 1.4 million HIV positive people, and so we need to reach much more people,” he says.
TAP provides support and funding for ARV drugs, home-based care and support, drugs to counter opportunistic infections in AIDS patients, voluntary testing and counseling, and prevention including mother-to-child transmission of HIV.
The largest program is in Mozambique, which delivers the services via DREAM and two other large international NGOs that were already operating in the country: Pathfinder International, and Health Alliance International (HAI).
In Burkina Faso, TAP uses large networks of small patient organizations that were built up from the grass-roots level by people living with HIV and others affected by the AIDS epidemic.
Ghana's program uses a public-private partnership approach to ensure private firms are involved in scaling up treatment, working through Family Health International (FHI), the National Catholic Health Services (NCHS), and the Private Enterprise Foundation (PEF).
The World Bank's Development Research Group (DECRG) is studying each country approach as part of research into the socio-economic benefits of antiretroviral therapy (ART) for patients and households, says Damien de Walque.
“Most doctors are happy to have saved a life, but ART brings additional benefits that are important to measure,” says de Walque.
The study looks at how the health of an AIDS patient affects their ability to work, as well as the impact of their illness on family members who care for them, and on their children, especially whether they are able to go to school.
It also looks at the effect of ART on HIV prevention—such as whether accessibility of treatment makes people more willing to be tested for HIV, or whether it causes people to perceive their risk as lower and relax their inhibitions about the disease.
“It's an important question. We don't want a lot of new infections. We're collecting data on that,” says de Walque.
The DEC team is studying households of patients and well as households in the general population for comparison purposes, he says. The team monitors each patient for 18 months; ideally beginning before treatment starts.
The research involves the households of 600 patients and 300 non-patient households in Burkina Faso; about 900 patients and 600 non-patients in Ghana, and a proposed total of 1,800 in Mozambique.
Data is also being collected at health facilities to measure the impact of the quality of treatment, such as wait times for service and whether patients were treated politely, as well as how well they adhered to treatment.
“The question is how do you promote adherence,” says de Walque. “It's important for treatment success. Poor adherence is likely to result in resistant strains of the virus.
“We're looking for an adherence mechanism that works.”