A response to IRIN/PlusNews list of six potholes in the road to significantly increasing HIV treatment coverage in Africa.

1. Cost:

The Joint UN Programme on HIV/AIDS (UNAIDS) has estimated that US$ 28 billion to US$ 50 billion would be needed globally every year from 2010 to 2015 in order to progressively reach universal access targets for HIV/AIDS by 2015. One-third of this will contribute towards the cost of the drugs.

The figure may sound “staggering” but it needs to be put in perspective with a few other figures such as:

• The cost of the World Cup 2010 in South Africa: $3.5bn
• The budget of the 2012 Olympics: $12bn
• The cost of the Trident nuclear submarine system: $147bn over 30 years
• The cost of the bank bailout in the UK: $1.3 trillion
• The budget deficit of the US: $1.5 trillion

To get an idea of how much a billion and a trillion look like see this site.

Now, if the 192 give-or-take countries that makes the world can’t scrap $28 miserable billion, there is a problem. And the problem is political will, not the economy.

As Peter Mugyenyi, Director of the JCRC in Kampala put it at the AIDS conference in Vienna. “The first argument was that Africa can’t do ART because the drugs require precision-timing and Africans have no watches. The second argument against treatment access was that Africa could not afford it, that even if ART was a glass of water, Africa could not afford it.”

The right question to ask is “When is the HIV bailout money going to come!?”.

Source: WHO

2. Low Testing number

There are numerous reasons behind low testing. Stigma, discrimination, access to VCT  are some of them. None are insurmountable and the volume of HIV testing as increased dramatically during the past few years .The reality is that “Nearly 90% of reporting countries had national HIV testing and counselling policies in 2008, up from 70% in 2007″.  There are evidences that people are willing to test, even in Africa. Knowing that treatment will be available is certainly a decisive factor but simply knowing one’s status,  wanting to protect one’s family are other reasons why people want to test. Fear and stigma can’t be allowed to win.

3. High-risk but “invisible” populations

There are two arguments here. The first is that high level of HIV prevalence is observed amongst marginalised population including sex workers, men who have sex with men, prisoners, and injecting drug users which are “hard to reach”. The second is that the behaviour of many vulnerable groups is also criminalised.

Both arguments are valid and relevant. However in 2008, the median percentage of those who had received HIV testing and counselling was 38% among sex workers (45 reporting countries), 23% among people who inject drugs (26 reporting countries) and 30% among men who have sex with men (31 reporting countries). With the exception of IDUs, these figures are in line with the median percentage of people living with HIV who knew their HIV status:  40%. Accessing VCT and accepting it is a global problem that does not only affect “invisible” population.

More efforts are needed and the potential of Test and Treat is that for it to work all need to have access to testing and treatment. Therefore implementing Test and Treat will require combined interventions aiming at fighting stigma and decriminalising sexual behaviours. In this regards, Test and Treat is “a package” that must be sold “as is” and can contribute to better access and increased human rights. This will have to be made clear to countries with dubious human rights.

The right question to ask is “What are government doing to end stigma and discrimination? What pressure are they putting on countries that criminalise MSM, IDUs, sex workers, migrants?”

4. Loss to follow up

This argument is not strictly a Test and Treat problem. It happens with all kind of treatment from taking antibiotics for a cold (do you always complete your 7-day course or do you stop after 4 when you feel better?) to completing an immunisation schedule to let’s say Hepatitis B?

This is a communication problem and there are several community and technology-based programmes that can improve follow up.

Source: WHO

5. Drug Resistance

Drug resistance is largely the result of poor adherence. Improving adherence using means similar to that used to improving follow up will realtivise the risk of large-scale drug resistance developing. Drug resistance will always occur but it can be delayed and cost of second line drugs, though still expensive are and will continue to decrease.

6. Risk compensation

The idea that people will take more risks because they are on treatment is still open for debate both in the developed world and in developing countries. It has been shown both for treatment as for biomedical intervention such as circumcision that behaviour was not neccessarily affected following the intervention. Some studies have even showed that condom use increased after starting treatment. Efforts must be made in parallel to Test and Treat to prevent changes in behaviour.

The Bottom Line

The bottom line of Test and Treat is that even if it does not reach its full potential, in many case it will simply be about providing treatment to people who already need it. Forty percent of patients with HIV in Uganda only have their infection diagnosed when they are already ill because of HIV. 54% of those who are diagnosed with HIV in the US need to start treatment at the time of diagnosis.

Ultimately, Test and Treat will contribute to extend universal access (which should have been achieved by 2010) and save life.

Further reading

TOWARDS UNIVERSAL ACCESS – Scaling up priority HIV/AIDS interventions in the health sector 2009

RESOURCE SCENARIOS 2011-2013 – Funding the Global Fight against HIV/AIDS, Tuberculosis and Malaria

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