The Treatment Era: ART in Africa

Sunday 17 December 2006
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The Treatment Era: ART in Africa

AFRICA: Interview with Dr Jim Kim, director of WHO's HIV/AIDS department

Dr Jim Kim, Director HIV/AIDS Department, WHO

In 2003 the World Health Organisation (WHO) joined UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria to declare the lack of access to antiretroviral (ARV) drugs a global health emergency. In response, WHO and its partners launched the 'Treat 3 Million by 2005' (3 by 5) initiative. PlusNews spoke to Dr Jim Kim, director of WHO's HIV/AIDS department.

QUESTION: After the problems seen in Arusha with the Fund's next round and donors' apparent reluctance to increase their funding, what guarantees of sustainability can mass antiretroviral therapy (ART) have? Are we urging poor countries to take on life-or-death commitments that are dependent on erratic outside funding?

ANSWER: Around the world, entire communities face social collapse because of the AIDS pandemic. The drive to provide treatment comes from affected countries and their leaders. WHO is working with ministries of health to provide technical assistance to help scale up treatment.

Because treatment is for life, long-term funding is essential to ensure that an entire generation will not be lost to HIV/AIDS. Current resources are the result of extraordinary advocacy efforts by communities living with HIV, activists, NGOs, faith-based organisations, leadership from heads of state and multilateral organisations.

There was nothing automatic about getting the funding we have, and there will be nothing automatic about sustaining it but, in my view, this is simply the task we are faced with if we are serious about tackling the worst pandemic mankind has faced for hundreds of years. Those of us who have the means to mobilise at a community, national and international level must do so to ensure appropriate resources.

The Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria has been a remarkable instrument in galvanising global treatment and prevention of HIV/AIDS. Three years ago, the Global Fund was an idea: since then it has raised US $3 billion - two-thirds of which is dedicated to HIV/AIDS - and are successful in rolling that money out into effective prevention and treatment programmes.

The United States President's Emergency Programme for AIDS Relief (PEPFAR) has committed $15 billion to AIDS relief globally and is also moving quickly. National governments have also increased funding for treatment - the British government recently doubled its international AIDS budget. New commitments from the World Bank, as well as the private sector and non-governmental, faith-based and community organisations, have also emerged.

Six million people living with AIDS need ART now, and this number is growing. The '3 by 5' target aims to mobilise the world to treat half of those in need - three million by the end of 2005. Continued long-term national and international support is essential to continue to move towards reaching the target. We simply must recommit ourselves to doing whatever it takes to meet the challenges ahead.

Q: To what extent has the recent controversy around generic companies withdrawing from the World Health Organisation's prequalification list threatened the survival of antiretroviral programmes?

A: What we are talking about here is short-term pain for long-term gain; it is about improving the overall quality of medicines for all poor people, not just those living with HIV. As drugs are relisted over the next few months, in the medium to long term I think we will all conclude that the prequalification process will have had a positive affect on scaling up treatment.

The Prequalification project, set up in 2001, is a service provided by WHO to facilitate access to medicines that meet unified standards of quality, safety and efficacy for HIV/AIDS, malaria and tuberculosis.

Prequalification was originally intended to give United Nations procurement agencies, such as UNICEF, the choice of a range of quality medicines. Countries most in need of life-saving ARV and other drugs often do not have the regulatory capacity to ensure the safety and quality of medicines from different suppliers around the world. With time, the growing list of medicines that have been found to meet the set requirements has come to be seen as a useful tool for anyone purchasing medicines in bulk, including countries and other organisations.

Companies wishing to have a product prequalified voluntarily submit a dossier to WHO, to allow qualified assessment teams to evaluate its quality, safety and efficacy. The manufacturer must also open its manufacturing sites to an inspection, comprised of regulatory experts from among 28 of the world's leading national regulatory agencies, including experts from Europe, Canada and Australia.

Ranbaxy Laboratories Limited informed WHO in November that it was voluntarily withdrawing all its antiretrovirals (product dossiers under assessment and all prequalified products) from WHO prequalification. This action was taken after the company found discrepancies in the documentation relating to proof of the products' bioequivalence with originator medicines.

The company has already presented WHO with a plan indicating proposed dates for the submission of new study reports for these products - the first study is expected to be completed by December 2004. Rather than threatening the survival of antiretroviral programmes, this withdrawal seeks to ensure the improvement of medicines.

[Information on the practical implications of the withdrawal of the above-mentioned products from the list of prequalified products for treatment programmes can be accessed on the WHO prequalification project web site, where the list of alternative products prequalified by WHO may also be found. []

Q: Isn't there a danger that the "positive living" aspect of HIV/AIDS treatment - better nutrition, for example - is being lost with all the focus on ART?

A: WHO supports positive living - good nutrition, exercise, etc. - but none of those things alone have ever been shown to halt the progression of HIV disease. The only intervention that has ever been shown to have a proven impact on mortality is ARV therapy. However, there is no question that good nutrition, exercise and many other aspects of healthy life can have beneficial effects for everyone, especially those living with HIV and AIDS.

Comprehensive programmes that integrate treatment and prevention, as well as the promotion of 'positive living', are essential. As access to treatment and prevention is increased within countries, health systems and infrastructures will be strengthened, which will have wide- reaching effects on improving public health services for everyone.

As more people are brought onto treatment, People living with HIV/AIDS visiting health centres for their treatment checkups will have increased opportunities to consult with a health professional about their overall health. A focus on ART does not mean the neglect of other, essential areas of care for [people living with HIV/AIDS] PLWHA - rather, it enhances these other areas.

Q: What do you think are the key components of a successful government rollout of ART?

A: The most important component is strong political will and commitment to implementing a comprehensive approach to HIV that involves accelerating both treatment and prevention. Leaders have the responsibility to stand up to AIDS and take the fight forward. We have already seen great progress in terms of leadership: we now have nearly $ 20 billion pledged for integrated AIDS prevention and care, and more and more countries are committing to scaling up treatment and care.

Partnerships and collaboration at country and international level between all stakeholders - national authorities, UN agencies, multilateral agencies, foundations, non-governmental, faith-based and community organisations, the private sector, labour unions and representatives of the community of people living with HIV/AIDS - are absolutely essential for successful rollout. Everybody has a role to play and all stakeholders need to work together, coordinating in line with the 'three ones' principals initiated by UNAIDS for one agreed HIV/AIDS action framework that provides the basis for coordinating the work of all partners; one national AIDS coordinating authority, with a broad-based multi-sector mandate; and one agreed country-level monitoring and evaluation system.

WHO works closely with ministries of health and others partners in-country, to design national HIV/AIDS plans and to identify existing gaps. Prevention and treatment needs differ from region to region, as well as country to country. The kind of assistance Belarus needs might be quite different from the needs of Swaziland or the Philippines. But what countries are consistently asking for is technical assistance to turn funding into national AIDS plans, and to turn plans into real programmes for people living with and affected by HIV/AIDS. WHO is working with countries to provide this technical assistance, but much more collaboration is needed.

Q: Beyond the rhetoric, are people living with HIV and AIDS really considered an asset in the response to HIV and AIDS, rather than the source of the problem?

A: HIV is non-discriminatory and can hit anyone at any time and in any walk of life. Conversely, PLWHA are absolutely central to the fight against HIV/AIDS and, from the beginning, it has been AIDS activists who have pushed society towards deeper dialogue and swifter action in fighting AIDS.

PLWHA live in the communities with the most need of prevention, treatment and care, and are best equipped to advocate for change. Never before have a group of people affected by a disease stood up so loudly and effectively to fight it. As ambassadors, PLWHA involved in the fight against HIV/AIDS can help defeat the epidemic like no one else.

WHO is involving PLWHA at every level of the drive to reach the '3 by 5' target. In November 2004, WHO awarded a $1.5 million contract to the Tides Foundation-Collaborative Fund, a global consortium of people living with HIV/AIDS, and treatment activists, to help prepare PLWHA for ART. In implementing the million-dollar grant, the Tides Foundation-Collaborative Fund is supporting more than 30 networks of PLWHA around the world in treatment preparedness activities, including treatment literacy projects and civil society advocacy initiatives.

The future of health belongs as much in the hands of those affected as those who care for them. People living with HIV/AIDS must be involved in all aspects of HIV/AIDS programmes and at all levels of decision-making and activity.


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