Global funding shortages and challenges in ensuring adherence to treatment are threatening to delay or even derail new recommendations that all HIV patients begin antiretroviral drug therapy as soon as they are diagnosed.
Developments in ART over the past two decades mean HIV patients who adhere to therapy have virtually no difference in life expectancy from people who are uninfected. Starting patients on treatment early also simplifies the public health response and prevents the spread of the disease, experts told Devex.
Yet last week’s International AIDS Conference in Durban, South Africa, underscored how officials, activists and researchers are still grappling with how to put the new World Health Organization protocol into practice. The international health body released the new policy late last year, citing its potential both to significantly reduce new infections and stave off HIV-related deaths.
The “test and treat strategy” could require extra donor funding in some countries, just as global support for HIV/AIDS is falling. UNAIDS, in a recent report laying out the costs needed to end the HIV epidemic by 2030, estimated the cost of hitting treatment targets in low- and middle-income countries at $19.3 billion next year.
“Unless we address the resources, then we may very well miss that 2030 goal,” said Dr. Linda-Gail Bekker, the incoming president of the International AIDS Society, which organizes the IAC. “Not because we didn’t have the tools or the inclination, but simply because we didn’t have the resources.”
A hopeful body of evidence
Read more stories in this series:
Since ART’s introduction in 1996, scientists have recommended that patients wait to start the drugs until their immune systems declined below a specified, measurable point. Those recommendations were based on high drug prices and limited understanding of the long-term health impacts of therapy.
New evidence, however, confirms that earlier treatment can keep people healthier, while also reducing their risk of transmitting the disease to others, the WHO determined. The organization changed its guidance for health care professionals on Sept. 30, 2015, and results presented at this week’s conference show it is already having some impact.
Researchers running a randomized trial in East Africa evaluating test and treat offered evidence that seems to indicate its potential to exceed even the most ambitious goals currently set by UNAIDS to defeat the AIDS epidemic. Those targets, known as 90-90-90, call for 90 percent of people living with HIV to be diagnosed and 90 percent of those identified patients then to start on treatment. Among the people who begin ART, the treatment should suppress the disease to the point it is undetectable in 90 percent of those patients.
Effectively, the 90-90-90 goal means that 73 percent of all HIV patients should reach a state of viral suppression. After two years, the East African SEARCH trial was able to achieve viral suppression of 82 percent. In addition to the benefits to their own health, virally suppressed patients are virtually incapable of passing the disease on to a sexual partner.
Dr. Deborah Birx, who heads the U.S. President’s Emergency Plan for AIDS Relief said test and treat offers the additional benefit of clarity.
“It simplifies public health management,” she said. Patients are diagnosed and, instead of waiting on countless test results to determine when they are given medication — sometimes over the course of years — treatment is almost immediate. “It makes [HIV] the same as any other illness,” she said.
Who will pay?
Despite the growing consensus around test and treat, the guidelines will be nearly impossible to implement unless new resources are found. According to a 97-country analysis from the research and consultancy group Palladium, nearly half of all facility-level ART costs that would come with test and treat between 2016 and 2020 could go unfunded.
In fact, international donor funding for HIV interventions in low- and middle-income countries is moving in the opposite direction. Commitments fell more than a billion dollars between 2014 and 2015 — from $8.62 billion to $7.53 billion, according to a report by the Kaiser Family Foundation and UNAIDS released just before the IAC. The ONE Campaign, which advocates for better healthcare in the developing world, has warned of an annual international funding gap for all HIV and AIDS activities that may reach as high as $12 billion.
Advocates need to “make sure that the traditional donors continue and scale up their commitment,” said Dr. Badara Samb, the chief of special initiatives for UNAIDS, who said there was also a need to look at new possible donors. Middle-income countries facing significant HIV epidemics are also being asked to increase their domestic commitments to the response.
South Africa’s health minister, Aaron Motsoaledi, recently announced that his country, home to the largest HIV epidemic, would introduce test and treat by September with an additional $70 million in budgetary funding. “Can this country afford not to when these people are sick?” he asked in presenting the plan at the IAC.
That will make South Africa one of only 22 countries have so far introduced test and treat as official policy, a situation Samb described as “not good enough.” He put the onus on UNAIDS and other international bodies to encourage countries to take up the strategy.
“It’s one thing to have your global guidelines, it’s another to really invest to explain the relevance of those guidelines,” he said. “To explain how important it is to pick up on those guidelines to reach where we want to be.”
Getting to treatment
Adoption is only the first step in meeting test and treat goals. Communities and individuals must also be convinced to get on board.
The challenges start with testing. “Trials, studies, programs are having to work really hard to get men to come and test,” said Dr. Carol Camlin, an associate professor at the University of California, San Francisco. She is part of the SEARCH trial team that is evaluating test and treat.
The SEARCH teams developed several ways to encourage men to come and test, including organizing opportunities around sports events and lotteries that offered rewards in exchange for participation.
“There were a lot of strategies that brought men into testing at remarkably high rates,” she said. “But it took a lot of work” — something public health systems will have to contend with as they roll out test and treat.
Keeping people on a treatment regimen designed to last an entire lifetime will also require new approaches. Dr. Chris Beyrer, who just ended his term as president of the International AIDS Society, said recent research indicates high rates of pregnant women dropping out of treatment after they successfully delivered and finished breastfeeding their children, for example.
“It looks like it’s going to be a problem for long-term care and prevention,” he said.
Different patients, different needs
One of the conversations dominating the IAC centered around differentiated treatment – the delivery of different kinds of care depending on the specific needs of communities and people. That includes initiatives like offering ART within neighborhoods, rather than making patients travel monthly to the clinic.
Dr. Francesca Celletti, the vice president of the Elizabeth Glaser Pediatric AIDS Foundation, said those different models might prove critical to keeping people on treatment.
“We cannot pretend that we use the same service delivery model for infants, children and adolescents and young women, compared to adults,” she said. “We have to differentiate by gender. It’s a paradigm shift that has to be put in place if you want to get to these people.”
If the international community is going to achieve the universal test and treat targets it has set itself, then it will have to reach those people — and figure out how to keep them. New approaches such as differentiated care might help. What is unclear, though, is whether that will be enough to overcome funding shortfalls.
Andrew Green reported from Durban on a fellowship with the International Reporting Project.
Access to Medicines is an online conversation to explore work being done to guarantee access to lifesaving medicines, where solutions are still needed. Join us as we look toward the future, tagging #access2meds and @Devex to share your thoughts.