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AIDS Is Not in Recession: Treatment Shortages Increasing

tagline 2009 August


HIV is not in recession: This was the recurring theme of the IAS conference repeated in speeches and displayed on PowerPoint presentations.


By Scott W. Morgan

At the Fifth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention in Cape Town, South Africa, this year, the AIDS Rights Alliance for South Africa (ARASA) won hands down for the most clever and effective advocacy campaign by handing out fake currency with international heads of state in denominations that reflect gross misuse of funds. A $250,000 currency note pictured Zimbabwe president Robert Mugabe enjoying his quarter-million-dollar 85th birthday party—a dollar amount that happens to be the rough equivalent of the cost of 10,500 courses of tuberculosis treatment. ARASA’s video on YouTube, Lords of the Bling, Volume 1, is a barbed portrayal of the abysmal failure of African heads of state to meet their commitments in the Abuja Declaration to increase health spending to 15% of the national budget of each leader’s country.

Among the fake currency notes bearing the slogan “Show Us the Money for Health” that ARASA handed out, a $700 trillion note sported the face of President Barack Obama, indicating the cost of the U.S. economic bailout. I can’t exactly compare Mugabe’s quarter-million-dollar birthday bash to the bailout, and I’m not downplaying the importance of the global crisis; the future of the AIDS epidemic would be considerably bleaker if other world economies followed the way of Iceland. However, as activists, public health professionals, researchers, and policy makers wrangle over each sliver of “the pie” allocated for global health, it’s hard to grasp that a multi-trillion-dollar “pie” bigger than any global health budget in history was appropriated and put to work in a matter of months. A mere two fiscal quarters later, U.S. executives are lining their pockets with huge bonuses that buy Hummers and other conspicuous consumer “bling.” In stark contrast, it has taken eight years to scale up antiretroviral (ARV) treatment to the point where only 4 million of the 33 million people who need it now or will need it in the future are actually on such treatment.

HIV is not in recession: This was the recurring theme of the IAS conference. It was repeated in speeches and displayed in PowerPoint presentations, and a pall hung in the rafters of the convention center as activists discussed the gravity of the financial shortfalls for treatment programs across the globe and the growing financial chasm that threatens to reverse the progress of ARV treatment rollout and scale-up that has been made in the past eight years.

Reports of “stockouts” (which occur when government and nongovernmental organization treatment programs do not deliver committed ARV treatment for enrolled patients) are increasing at an alarming rate. As of this writing, Uganda is investigating the deaths of 17 HIVpositive patients linked to stockouts. These people died during the past month after being unable to access their ARV drugs. Stockouts are occurring for a multitude of reasons, almost always leading back to lack—or poor management—of funding. Choke-points include ministries of health, ministries of finance, supply chains, and “registered” drug suppliers. Activists in Kenya, Malawi, Uganda, and Zambia recently carried out an “SMS pill check week” that uses SMS text messages on cell phones to gather information from publicsector health facilities about stockouts and low availability and are working to put a standard four-digit SMS code system in place that will allow patients and providers to report when drugs are not available. (See the interactive map at http://www.stopstockouts.org.) There is also mounting evidence that ARV treatment programs across sub- Saharan African countries are limiting or altogether stopping enrollment for fear they will not be able to handle the volume of current patients, let alone newly diagnosed people with HIV seeking treatment.

Widening ARV stockouts and growing lists of people with HIV infection waiting to gain access to treatment programs have consequences at the levels of both individual and general population health, to say nothing of the subsequent effects to community stability, overstretched family-based safety nets, and the everincreasing population of orphans. As people on ARVs face the prospect of being temporarily turned away from treatment (after having been counseled regularly about the importance of strict adherence), family members and/or friends start sharing tablets, cutting them to make them last longer—or they stop taking them altogether. Consequences are certain and often swift: viral loads will increase, CD4 counts will drop over time, and opportunistic infections will result in clinical manifestations of AIDS. Resistance from unchecked mutating virus replication will make it more difficult to treat these people when or if they can resume treatment before they die. Higher viral loads may result in increased levels of transmission at the population level, and mutations in the virus make first-line treatment fail more quickly. First-line treatment in resourceconstrained settings is already a colossal challenge to extending efficacy as long as possible. Access to second-line treatment is even more difficult—in large part due to huge price disparities: $80–$243 per person per year on first-line treatment to $620–993 per person per year for secondline treatment.

The global economy shows some signs of stabilizing. That’s good news for everybody, but for some more so than for others. Recipients of the U.S. Troubled Asset Recovery Program ($303 billion disbursed as of March 2009) posted billion-dollar profits in the second quarter and plan to hand out hundreds of millions of dollars in executive compensation. In Africa, people with HIV are being turned away from treatment that costs less than $1 per day.

In comparing the funding gaps being faced by proven treatment-access programs like the President’s Emergency Plan for AIDS Relief (PEPFAR) and The Global Fund to Fight AIDS, Tuberculosis and Malaria to the trillions of dollars that were pledged and disbursed in 2008 and 2009 to bail out Wall Street, one can only say “Show Me the Money for Health”!

Eight years ago, bureaucrats thought it was impossible to put people in resourcepoor settings on ARV treatment; today there are 4 million people receiving lifesaving treatment. The G20 and the global community must not shirk commitments and responsibilities to the 4 million people on ARV treatment or the estimated 29 million people who are HIV positive and will soon need access to such treatment.

As Nobel laureate Françoise Barré- Sinoussi concluded her plenary speech at the Fifth IAS Conference, “We can predict that reducing the international efforts on universal access to [antiretroviral therapy] because of the global recession will be a disaster . . . HIV is not in recession!”

Visit ARASA at http://www.arasa.info/healthmoney and sign the petition: An Open Appeal to African Heads of State.

Watch the Lords of the Bling, Volume 1 video at http://www.youtube.com/watch?v=MkWoKgLhDVs.