Q&A: Moving money around in HIV care

Duncan Blair, vice president of public health initiatives at Abbott, speaks at the 22nd International AIDS Conference. Photo by: Marcus Rose / IAS

AMSTERDAM — At last week’s 22nd International AIDS Conference, the global health community watched as foundations reaffirmed commitments, new research was rolled out, and the latest technologies were unveiled — all in a bid to shine a spotlight on the current status of HIV/AIDS, and the efforts still needed to tackle it.

But with many years of research, innovation, and community-level work already behind us, what are the gaps that need to be filled in order to reach UNAIDS 90-90-90 goals?

Q&A: Diagnostic tools as the answer to HIV and AIDS

Abbott rolls out a new point-of-care diagnostic test for HIV/AIDS designed to work in remote and under-resourced settings. The organization's Dr. Kuku Appiah tells Devex how this has the potential to accelerate treatment, prevent transmission, monitor the emergence of drug resistance, and overall, contribute to the UNAIDS 90-90-90 goals.

A lack of diagnostic tools, flat funding, and barriers to market access are some of the issues Duncan Blair, vice president of public health initiatives at health care technology company Abbott, believes need to be addressed.

“I don’t think flat funding will reverse progress per se, but what has happened is that progress has stalled,” he explained. “I think we need to look at where the impact is and where we should spend the money in a better way to have more of an impact.”

At the end of 2017, according to the World Health Organization, there were 36.9 million people living with HIV and the disease claimed the lives of 940,000 that year alone. While antiretroviral therapy, or ART, is now an available treatment, in many countries a lack of access to health care facilities for diagnosis, treatment, and sexual education remains a barrier to ending the HIV/AIDS epidemic.

“If we keep doing the same we’ll fail to progress and we won’t achieve the [90-90-90] targets,” said Blair.

Sitting down with Devex at the conference, he explained that in order to reduce the number of people living without a diagnosis — it’s estimated that only 75 percent of people with HIV know their status — or receiving inadequate care, there needs to be a shift in financing, innovation, and technology. Blair also shared his perspective on the role of the development community in expediting progress.

The conversation has been edited for length and clarity.

Do you think there is a deficit when it comes to diagnostics for infectious diseases such as HIV in low-resource settings?

Absolutely. Depending on which data you look at, in high-income settings anything between 30 and 70 percent of clinical decisions are made on the basis of a diagnostic test of some sort — whether it's an in vitro diagnostic, radiology, or something else. In low-income settings, it may be as low as 5 or 10 percent, so you could argue that maybe there's a bit too much in the high-income settings, but I think it's very clear that this is too little in the low-income settings.

If there's a finite amount of donor financing for health in low-income settings, more of that needs to be redirected toward the diagnostics and a little bit less toward the pills. We’re probably overtreating, or rather mistreating, people in some conditions — malaria is a clear example. There's far too much malaria treatment happening, but not enough diagnostics being done so that we actually know who truly needs malaria treatment versus who has some other febrile illness requiring completely different care.

How can this be remedied?

Increased funding would be welcome. I think the reality is we do see flatline funding, but a key point is the need to refocus the existing funding. The reality that we face doesn't seem to go in that direction. Shifting some of the money toward diagnosis would be welcome.

If global funding for public health is flatlining, why should donors and HIV programs invest in deploying new point-of-care technologies when they’ve spent years investing in big laboratories?

If we keep doing the same thing and expect a different result, we're not going to get anywhere. As you say, it's been a tremendous investment in lab infrastructure to date over the past decade or so. It's gotten us to a certain point, but as the funding flatlined, so too has the impact.

What we've seen at this conference — and over the past one to two years — is that deploying point-of-care technology actually helps us reach an unreached population. We need to think about how to spend our money in a smarter way to achieve bigger impacts. We can't just keep pumping money into the same old thing.

“We need to think about how to spend our money in a smarter way to achieve bigger impacts. We can't just keep pumping money into the same old thing.”

— Duncan Blair, vice president of global public health at Abbott

I can't speak to where the donors will redirect their funding, but what I can speak to is some of the evidence and data that have been presented that show you can achieve a far higher impact.

If we look specifically at early infant diagnosis of HIV, the Elizabeth Glaser Pediatric AIDS Foundation, in particular, has publicly available dashboards which show that by using their funding to implement point-of-care versus the standard conventional technology, they moved from getting 50 percent of kids on treatment to over 90 percent of kids on treatment.

There is undoubtedly a place for both conventional and point-of-care early infant diagnosis, but I think this work by EGPAF and others should now inform the donor community about how to focus their investments in the future.

What should global development and health actors do to really accelerate progress?

I'll address that by focusing on one of the key challenges we face after having developed a new technology, which is the barriers to the market access. We have to prove that our technology works — and that’s absolutely fair and appropriate; we have to prove that it meets a quality standard.

But the challenge is when we bring the new technologies, we often face study after study, pilot after pilot, which repeats the same work and adds little value to the overall intellectual contribution to what can be done with this technology. It just seems to be a lot of repetition, a lot of wastage, and ultimately delayed access.

How the global development and implementing community could help is by moving to a situation of speedier adoption once something is proven to be safe, efficacious, and impactful. Donors in particular have an opportunity to help with that because, while country ownership of health programs is clearly critical, at the same time donors can and do choose how their money is spent and then reported on, to some extent.

Moving away from simply repeating dozens of studies to a large-scale implementation, with monitoring, so that you can tell if your intervention is working, would be really helpful. It would be enormously beneficial to the patients we’re trying to serve and it will give greater certainty to industry about where they should invest their dollars in research and development.

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