© Brendan Bannon
"Donors have been shifting their focus from AIDS to other diseases, where there is a sense that more lives can be saved more cheaply. At a time when we should be scaling up to meet the AIDS challenge, in other words, we are dialing back. In our global war on AIDS, the international community is on the verge of snatching defeat from the jaws of victory."
-- UN Secretary General Ban Ki-Moon,14 June 2010
The past decade is testimony to the fact that treating AIDS in developing countries is feasible, saves lives and rebuilds devastated communities. But donors are now starting to shift their support away from HIV/AIDS, and MSF has seen the tangible effects this funding retreat is already having: care rationed because of limited treatment slots, treatment scale-up halted for those in urgent need, and an even more distant promise of universal access. The decade ahead of us should not be spent undoing the hard-won advances.
The AIDS funding retreat will have the following consequences:
Limiting treatment slots means choosing who lives or dies: Because of funding cuts, treatment providers are being forced to turn people in need of treatment away from clinics in some countries, having been forced by lack of funds to only enroll new patients on treatment when others die or default.
Delaying or deferring treatment encourages transmission, illness and death: Providing ART earlier lets people live healthier lives, reduces the incidence of opportunistic infections, and decreases the need for resulting care and hospitalisation. It also reduces the number of people lost to follow-up before they start treatment. With increasing evidence that treatment is prevention, failing to provide treatment earlier also allows the virus to spread.
Failing to ensure a stable drug supply means viral load shoots through the roof: Reduced funding leads to volatility in drug supplies, which can lead to dangerous treatment interruptions. Without the virus being constantly suppressed through ARVs, people can rapidly fall ill again and die, and drug-resistant strains can spread.
Breaking the promise of ART means people won’t come forward to get tested: People came forward to get tested because they knew treatment was available should they test positive. If people in need to treatment come to believe this is no longer true, the hardwon progress on encouraging people to know their status will come undone, with potentially disastrous ramifications.
Slowing AIDS efforts means the number of kids infected with HIV will rise: Children’s needs have consistently lagged behind adults for AIDS treatment. Badly needed diagnostic tests and drug options for children will be even less of a priority in a reduced funding environment. Improved WHO-recommended protocols to prevent transmission of the virus from mother-to-child (PMTCT) will also likely fall by the wayside, meaning the needless infection of newborn children.
Slowing down the integration of HIV and TB care means patients will slip through the cracks: TB remains the number one killer of people living with HIV/AIDS, and providing integrated care for both TB and HIV/AIDS is the most effective way to tackle this dual epidemic. But such integration has only barely begun in endemic countries, and waning support for HIV/AIDS care will slow it even further.
Choosing between maternal & child health or AIDS means making a false choice: AIDS is the main killer of women of childbearing age and over 40% of deaths of children under five years in six southern African countries are because of AIDS. Addressing AIDS creates positive knock-on effects in other health areas. More funding should be allocated to global health rather than withdrawing support from one area to fund another.
Calling an end to decentralisation of care mean it’s harder to reach people in urgent need: Bringing AIDS treatment close to where people live reaches more people in need and lowers the rate of patients lost to follow-up. This is a particularly effective way to scale up ART in areas that are hard hit by severe health worker shortages. But without support, it will not be possible to expand this successful model.
Continuing to use drugs with more side effects means relegating patients to second-class care: WHO has recommended that less-toxic drugs be used in first-line treatment, as part of the effort to close the treatment gap between rich and poor countries. This means substituting stavudine, with significant side effects, for tenofovir (TDF), or zidovudine. Despite prices falling, the cheapest TDF-containing regimen is still more expensive than older alternatives. However, using TDF decreases the cost of managing side effects through medical care and/or hospitalisation, thereby proving more cost-effective in the long run. The provision of less-toxic medicines cannot be prioritised if funds are short.
Cutting back on funding for treatment means sacrificing long-term survival: AIDS is a lifelong disease and patients inevitably need to be switched to newer regimens as drug resistance develops over time. But treatment failure is a hidden problem because of a lack of affordable and accessible viral load testing. Further, newer medicines are much more expensive. This means that patients are less likely to be switched when necessary, and even less so when there is reduced funding for AIDS treatment.
Donors are walking away from AIDS when 10 million people are still waiting for treatment. Help us stop the U-turn on AIDS. http://aids2010.msf.org
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