Treatment works

Advocacy brief

Left: Joseph Jeune before treatment for HIV/AIDS /TB co-infection, March 2003, Right: Joseph Jeune after treatment for HIV/AIDS /TB co-infection, September 2003 (David Walton/PIH)

THE CHANGING FACE OF HIV/AIDS

The two photographs above show how the history of HIV/AIDS is changing. Joseph Jeune is a 26-year-old peasant farmer in Lascahobas, a small town in central Haiti. When the first picture was taken in March 2003, his parents had already bought his coffin. Suffering from the advanced stages of AIDS, Joseph Jeune probably had only weeks to live. The second picture, taken six months later, shows him 20 kg heavier and transformed after receiving treatment for HIV/AIDS and tuberculosis co-infection.

Joseph receives care in the small clinic in his home town. The clinic’s HIV/AIDS and TB treatment programmes are part of a wider initiative to strengthen the health service infrastructure across much of Haiti’s central plateau. The effort involves nongovernmental organisations, the public sector and communities, with major support from the Global Fund to fight AIDS, TB and Malaria. Using antiretroviral therapy as an entry point, the programme is building up primary health care in communities, for a total population of about 260 000 people. It does so through improved drug procurement and management, the expansion of HIV counselling and testing, increased salaries for local health care personnel and the training of numerous community health care workers. Primary care clinics have been refurbished, restocked with essential medicines, and provided with new staff. They are receiving ten times more patients for general medical care daily than before the project began.

Projects like this can bring the medical treatment that saved Joseph Jeune to millions of other people in poor and middleincome countries and how, crucially, such efforts can drive improvements in health systems.

BRAZIL SHOWS THE WAY

Brazil has the most advanced national HIV/AIDS treatment programme in the developing world. By mid-2002, the programme had 115,000 participants. It is estimated that between 1994 and 2002, almost 100,000 deaths have been averted in Brazil (a 50% drop in mortality) through the introduction of ART.

As a result of this programme, there has been a significant decline in the number of hospital admissions. Cost savings in reduced hospital admissions and opportunistic infections are estimated at more than US $ 1 billion. The programme has also been effective in reducing the rates of TB and other opportunistic infections.

The viability of the Brazilian HIV/AIDS programme, including treatment distribution, owes much to effective social mobilization, including representation of affected communities in government, non-governmental organizations, and other fora. The distribution of free antiretrovirals in itself prevented the problems associated with black market or substandard regimens.

ANTIRETROVIRAL THERAPY IN THE WESTERN CAPE PROVINCE, SOUTH AFRICA

South Africa’s first public sector project offering ART was established at community health centres in the Cape Town township of Khayelitsha, where clinics began treatment in May 2001. By June 2003, over 5000 patients had enrolled and over 600 children and adults had started treatment. The costs of drugs, viral load tests and the wages of half the clinical staff have been met by Médecins Sans Frontières; the remaining costs have been covered by the provincial government.

Adherence, survival and virological success in this project are comparable to if not better than those in many settings in wealthier countries. The potential to treat families in one primary health care setting, to connect with community-based support groups and nongovernmental organizations, and proximity to referring services all contribute to impressive clinical outcomes.

The province is attempting to bolster the entire primary care system in tandem with the delivery of ART. Primary care services are benefiting from the strengthening of referral systems with hospitals, the provision of clinical support by specialists, and the increased emphasis on drug availability. Nurses with no formal training in diagnostics and curative care have rapidly become competent primary care clinicians through training and mentoring in HIV/AIDS care. Increased resources (both human and financial) have been directed at primary care as a result of the work of these projects. There has been a reinvigoration of clinical support networks, increased uptake of a range of services including voluntary counselling and testing, and more openness about HIV/AIDS.

CAMBODIA AND THAILAND – SUCCESSES AND CHALLENGES

HIV infection in Asia remains largely confined to those people at higher levels of risk – sex workers, injecting drug users, men who have sex with men – and their sexual partners. Those at elevated risk represent anywhere from 7% to 25% of the adult population, making severe epidemics a possibility in all the countries of the region.

However, the focused nature of risk means in turn that focused nature of risk means in turn that focused prevention efforts with high coverage can slow or reverse the course of the epidemics. By mounting intensive, well-funded and extensive efforts to reduce the risks in sex work, Cambodia and Thailand have changed the course of their epidemics. In both countries, the role of sex work in HIV transmission was realized early on and major nationwide prevention efforts were mounted, working not only with brothel owners and sex workers, but also reaching out to the large client populations – almost 20% of adult males in the early 1990s. In response to these programmes, condom use between sex workers and clients rose to more than 90% and the number of men visiting sex workers was halved.

Using this Asian Epidemic Model, the East West Center and its collaborators have explored the impacts of these prevention programmes. Without aggressive prevention programmes it is estimated that both countries would now be looking at expanding epidemics with 10 – 15% of their adult populations living with HIV/AIDS, instead of the declining epidemics of 2-3% currently seen.

But as one avenue of HIV transmission is closed off, others appear. Programmes for injecting drug users (IDU), men who have sex with men, and sexually active young people have been weak and ineffective to date. The epidemic among injecting drug users in Thailand continues unabated, condom use among young people remains low at around 20% and there are HIV levels of around 15% in men who have sex with men. If the two countries are to sustain their past successes they must adapt responses to be as effective and aggressive with new evolving patterns of risk.

PREVENTION AND TREATMENT IN BRAZIL AND THE BAHAMAS

The Brazilian experience shows that scaling up antiretroviral treatment enhances, rather than impedes, prevention efforts if they are scaled up simultaneously. Since 1996 (the year Brazil’s universal antiretroviral drug distribution programme began), sexual behaviour, and more recently HIV prevalence, have been monitored among nearly 30 000 army conscripts. In 1999–2002, over 80% of the conscripts were sexually active and the proportion with multiple partners remained steady; but HIV prevalence among the men was low (0.08%) and condom use was high and increasing. In 1999, 62% of men reported condom use at last sexual intercourse, and in 2000 and 2002 70% did so. Condom use with a paid partner in the previous year increased from 69% to 77% in 2002.

The impact of prevention interventions was also observed among IDUs. The most significant reduction in the index of sexual risk behaviour was found in the group.