AFRICA: Six challenges to delivering treatment as prevention

Vienna, 20 July 2010 (PlusNews) - Using HIV treatment to drastically reduce transmission of the virus is the big issue at the International AIDS Conference in Vienna; scientists and health workers are optimistic but recognize that scaling up treatment will not be easy, especially for poor countries.

IRIN/PlusNews has put together a list of six potholes in the road to significantly increasing HIV treatment coverage in Africa.

Cost – Achieving universal access to treatment, based on revised treatment guidelines by the World Health Organization, would cost an estimated US$2 billion over the next five years, according to Bernhard Schwartlander, UNAIDS director for evidence, strategy and results.

The figure is staggering, especially at a time when HIV funding is flagging. AIDS activists are hoping to convince donors that spending more on treatment now will avert the costs associated with starting patients on treatment late, thereby saving money in the long run.

Low testing numbers – Drastically increasing the number of people on treatment means many more will have to be tested. Although testing numbers are rising, the World Health Organization (WHO) reports that in most African countries less than 20 percent of the population has been tested.

The WHO has recommended changing from voluntary counselling and testing to provider-initiated services, meaning that health workers routinely offer patients an HIV test rather than waiting for them to ask for one.

Kenya is running a high-profile door-to-door testing campaign, and Lesotho has tried a similar approach. However, activists cautioned that provider-initiated testing needs to be accompanied by respect for human rights, especially in cultures where an HIV-positive test could have negative social consequences.

High-risk but "invisible" populations – In many African nations, sex workers, men who have sex with men, prisoners, and injecting drug users have high levels of HIV prevalence, but often live outside the law and, as a result, HIV services rarely reach them.

In several countries, including Burundi, Malawi and Uganda, laws penalising men who have sex with men are becoming more severe.

Achieving universal access to treatment will mean including these populations in testing and treatment programmes. To this end, activists are urging countries to decriminalize homosexuality, sex work and injecting drug use.

Loss to follow-up – Many African HIV treatment programmes have difficulty retaining the patients they already have, partly because they lack the resources to track down patients who miss clinic appointments and stop taking their ARV medication.

Not adhering to treatment often leads to patients developing resistance to first-line medicines and having to switch to more expensive, often unavailable, second-line drugs. Putting more people on treatment is likely to put even more pressure on already over-stretched health and community workers.

Simpler, better community-based health programmes to track HIV patients will need to become commonplace; such programmes have achieved positive results in East Africa.

Drug resistance – As more people are put on treatment, there are growing concerns about the development of large-scale drug resistance.

At US$425 per person per year, the cheapest second-line drug combination available costs nearly five times more than the cheapest first-line combination; third-line combinations cost over 10 times more.

Better patient monitoring, including more efficient record-keeping, the use of community health workers and cheaper, simpler tests to determine CD4 count (a measure of immune system strength) and viral load (the amount of HIV in the blood) would go a long way towards reducing drug resistance.

Risk compensation – There is a concern that HIV-positive people on ARVs may view treatment as a substitute for condom use and engage in risky sexual practices. In a recent US study, gay men said they were likely to reduce their condom use if pre-exposure prophylaxis (the use of ARVs to prevent HIV in high-risk groups) proved to be effective.

To combat this, it will be important to scale up prevention along with treatment by increasing the availability of condoms and improving sex and HIV education in schools.

kr/ks/he

Theme (s): Care/Treatment - PlusNews, HIV/AIDS (PlusNews), Prevention - PlusNews,

[This report does not necessarily reflect the views of the United Nations]