God, AIDS, Africa & HOPE

Global funding for AIDS needs to increase by one-third in the short term and by 20% in the longer term in order to achieve a radical reduction in new infections within a  decade, according to projections issued on June 3^rd by UNAIDS. UNAIDS executive director Michel Sidibé told reporters ahead of this week’s UN General Assembly Special Session on AIDS, that UNAIDS was pushing world leaders to commit to a target of treating 15 million people by 2015, and to a major increase in funding in order to decisively alter the course of the epidemic over the next decade. The agency also reported that 6.6 million people worldwide are receiving antiretroviral treatment, with 1.4 million people starting treatment in 2010 alone.  UNAIDS estimates that 34 million people are living with HIV worldwide. According to the AIDS at 30 report, the global rate of new HIV infections declined by nearly 25% between 2001 and 2009. In India, the rate of new HIV infections fell by more than 50% and in South Africa by more than 35%; both countries have the largest number of people living with HIV on their continents.

However UNAIDS also reported that funding for HIV prevention, treatment and care fell for the first time in 2010.

“I am worried that international investments are falling at a time when the AIDS response is delivering results for people,” said Mr Sidibé. “If we do not invest now, we will have to pay several times more in the future.” A highly detailed modelling exercise led by the World Health Organization suggests that an increase in funding of one-third between now and 2015, coupled with a much tougher approach to funding only what is known to work, could avert 12.2 million new HIV infections over the next decade. What UNAIDS and WHO call an investment framework is led by the principles of `know your epidemic and know your response`, and seeks to channel funds in a much more rigorous way towards interventions that are known to work, and towards populations at greatest risk of infection. The modelling work found that the most targeted approaches were likely to have biggest impact on new infections. For example, a comparison of a `broad and shallow` or a `narrow and deep` programme in KwaZulu-Natal, South Africa, found that achieving 80% coverage of antiretroviral therapy and circumcision of 70% of uncircumcised men had a substantially greater effect on HIV incidence over ten years than a wider programme that also sought to increase condom use, counsel individuals on risk reduction and promote microbicide use in women, all at low levels. The `broad and shallow` approach assumed much lower levels of treatment access and circumcision. The impact of a `narrow and deep` approach was even more profound in Karachi, Pakistan, where a highly targeted approach that focussed on 80% treatment coverage and 80% access to needle exchange and opioid substitution had a much greater impact on new infections than a broad approach which delivered lower levels of treatment and harm reduction alongside behaviour change interventions. The `narrow but deep` approach might reduce new infections in Karachi by over 80% within six years, the modelling exercise concluded. However, the researchers are not advocating that all countries follow this approach; the allocation of resources is highly dependent on the epidemiological context. The model estimated resource needs for 139 countries based on epidemiological data and information on current coverage of prevention, treatment and care.

The model showed that if applied across all countries, global resource needs would rise from the current need of $16 billion per year to peak at $22 billion in 2015, before beginning to fall back gradually as a result of economies of scale and a decline in new infections. Requirements for the core programme activities – treatment and care, condoms promotion and distribution, prevention of mother to child transmission, male circumcision and behaviour change programmes – rises from $7 million in 2011 to $12.9 billion in 2015 and then falls back to $10.6 billion in 2020. This costing assumes that 13.1 million of the 18.3 million people eligible for treatment will be receiving it by 2015, and 18.7 million by 2020. Expanding treatment to provide antiretrovirals to all HIV-discordant couples where the partner with HIV has a CD4 count between 350 and 550 – the group studied in the recently announced HPTN 052 study – would increase the number in need of treatment by 1 million in 2015, and would add $500 million to the cost of the framework package by 2015.

New infections are predicted to decline from about 2.4 million in 2011 to 1 million in 2015 and 870,000 a year in 2020. The new framework could avert 12.2 million new infections between 2011 and 2020, including 1.9 million in infants. In addition, expansion of treatment would avert 7.4 million deaths over the same period. Treatment for HIV-discordant couples above the currently recommended threshold for starting treatment would avert an estimated 340,000 infections. The researchers estimate that the cost per-life year gained of the interventions in the framework is $1060, making it affordable for even the poorest countries. Any health intervention which costs less than the GDP per capita of a country is judged highly cost-effective by the World Health Organization. The massive expansion in treatment numbers would be facilitated by community mobilisation and by large reductions in the cost of drugs and treatment delivery, the authors say. In particular the model assumes that previous cost reduction trends will continue, allowing a 65% reduction in the cost of treatment between 2011 and 2020. A shift towards delivery of antiretroviral treatment through primary care and community-based care will be critical in achieving the cost reduction. But reluctance is being expressed by the governments of wealthy country governments to sign up to new targets for treatment expansion at this week’s UNGASS meeting. Furthermore, activists monitoring the negotations on a final declaration say that wealthy countries are also trying to water down any commitment to improve access to medicines in the final statement. “We are seeing an unusual position being taken by the EU which is refusing to commit to any treatment targets and at the same time is working with the US to remove or significantly dilute any language in the text related to increasing access to safe, effective and affordable generic medicines,” said Matthew Kavanagh of Health GAP (Global Access Project).

Language proposed by the nations facilitating the UN process, Botswana and Australia, on trade agreements and the removal of any and all TRIPS-plus measures from free trade agreements has been rejected by the EU. They are joined in this by the United States and Japan. TRIPS-plus measures seek to enforce higher standards of intellectual property protection on developing countries as the price of access to the markets of the wealthiest nations. These measures may undermine opportunities to use TRIPS flexibilities that allow low and middle-income countries to manufacture and / or export antiretroviral drugs that are still patented in wealthy countries. These measures may stand in the way of manufacturing new antiretroviral combinations that are cheap, less toxic and less prone to drug resistance, and may also choke off the supply of cheap drugs for second-line antiretroviral treatment in those whose first drug combination has failed to control HIV.

Schwartlander B et al, on behalf of the Investment Framework Study Group. Towards an improved investment approach for an effective response to HIV/AIDS. The Lancet, advance online publication, June 3, 2011. (View full text article here).