Health experts and scientists have accused the world's wealthiest countries of abandoning the goal of universal access to HIV prevention, care and treatment by 2010. ‘We must hold the G8 leaders accountable for their failure to deliver on their promises,’ said Julio Montaner, president of the International Aids Society (IAS), on opening the Fifth IAS Conference on Pathogenesis, Diagnosis and Treatment in Cape Town on 19 July. Montaner, who is also director of the British Columbia Centre for Excellence in HIV/AIDS, was sharply critical of the world's most powerful industrialised countries, who in 2005 committed to developing a comprehensive response to the AIDS pandemic that would achieve universal access to treatment by next year, yet have failed to renew these promises at the G8 summit held from 8–10 July. ‘HIV/AIDS was indeed the elephant in the room,’ he said. ‘In 2009, the eight most powerful economies in the world left HIV off their priority agenda.’
Equity and HIV/AIDS
Pharmaceutical giant GlaxoSmithKline has announced plans to invest up to US$97 million over 10 years in improving antiretroviral (ARV) treatment for children and adults in sub-Saharan Africa. The world's second largest drug manufacturer has already pledged US$16 million in seed funding to a public-private partnership that will develop new paediatric formulations of ARV drugs. Less than 10 percent of patients on ARVs in Africa are children and, although thirteen ARV formulations specifically for children are available, they are not adapted for use in resource-poor settings. Most are in liquid form, and come as three, often unpalatable, separate drugs that children find difficult to take. The company has also launched a new ‘Positive Action for Children’ fund of US$80 million over 10 years to help prevent mother-to-child transmission of HIV, and to support orphans and vulnerable children. It made the announcement after activists and governments put pressure on drug companies to do more to make life-saving medicines available in developing countries.
This study’s main aim was to determine what US$577 million in funding from the US President’s Fund for AIDS Relief (PEPFAR) between 2004 and 2008 has achieved in Zambia. Its findings are based on interviews with HIV and AIDS organisations, activists, medical professionals, community leaders, policymakers and programme participants. PEPFAR followed the ABC (abstain, be faithful and use a condom) approach to HIV prevention in Zambia but, according to this report, in 2008, US$20.5 million was channelled to programmes focused on abstinence and being faithful, compared to only US$12.4 million allocated to programmes promoting other approaches, including the use of condoms. Only four organisations received funding to promote condom use. ‘The disproportionate emphasis on abstinence-until-marriage [...] has created a distinctly anti-condom atmosphere,’ the authors noted. They recommended more extensive sex education programmes.
Widespread early therapy for HIV is intellectually compelling because it targets viral load, the major biological risk factor for transmission and disease progression. Delaying treatment until HIV has inflicted severe damage on the immune system and further transmission occurs is a different practice to the approach of other infectious diseases such as tuberculosis. Earlier diagnosis and treatment offer opportunity for ‘positive prevention’, emphasising other health interventions, as well as enhancing the sexual and reproductive health and rights of persons living with HIV. Papers published in 2008 suggested anti-retroviral therapy (ART) may be considered a means of limiting HIV spread, as it reduces viral load. One paper reported that annual universal voluntary HIV testing followed by immediate ART could reduce HIV incidence by about 95% within a decade, with cost-saving over the medium term. Nonetheless, the world requires stronger evidence before policy development on ART for HIV prevention can be envisaged.
The objective of this study was to gain a greater understanding of published safety data for candidate vaginal microbicides. It systematically reviewed twenty-one human safety trials in peer-reviewed journals, involving the use of 11 vaginal microbicides by a total of 1,465 women. There were few findings of significant difference between women in active and control arms of trials. Confidence intervals in the analyses were generally very wide, and most studies were unable to exclude differences of a substantial magnitude between treated and control women. Larger and longer safety studies are necessary to detect clinically important toxicities, including those that indicate a potential increase in HIV risk, before they are ready for large-scale effectiveness trials and use in the public sector.
It is becoming clear that HIV/AIDS spreads most rapidly among poor, marginalised, women, colonised and disempowered groups of people more than others. The HIV/AIDS epidemic is exacerbated by the social, economic, political, and cultural conditions of societies such as gender, racial, class, and other forms of inequalities. Sub-Saharan African countries are severely hit by HIV/AIDS. For these countries the pandemic of HIV/AIDS requires them to go the extra mile in their efforts. The objective of this paper is to promote the need to go beyond the biomedical model of ‘technical fixes’ and the traditional public health education tools, and come up with innovative ideas and strategic thinking to contain the epidemic. It argues that containing the HIV/AIDS epidemic and improving family and community health requires giving appropriate attention to the social illnesses that are responsible for exacerbating biological disorders.
A new report released before The High-Level Forum on Advancing Global Health in the Face of Crisis, which took place on 15 June 2009, suggests that the response to AIDS is an opportunity to improve health systems worldwide. Other areas that contribute to health solutions, such as human rights, the law and education, need to be embraced to maximise outcomes, and health equity must be addressed. The report argues that the main issues that need to be addressed are: the shortfall in health resources, despite increases in investment in global health; the need to strengthen community services, despite the beneficial effects from an increase in AIDS resources being spent on health and community systems; the need to link AIDS treatment and HIV prevention to other health issues, such as sexual reproductive health, tuberculosis and safe motherhood. A lesson learned is that social determinants, such as gender inequality, lack of education and poverty, must be addressed when addressing global health needs.
A three-day summit on HIV and AIDS in May this year called on governments to depoliticise the fight against HIV and AIDS and take the lead in fighting the scourge rather than leave it to donors and lobbyist. the Global Citizens Summit held in Nairobi represented citizens from 32 nationals among them National AIDS Control Council representatives (commissioners) from seven countries in Africa and donors from Europe and the Americas. There were calls to ensure that citizens take their rightful place in the fight. Two recommendations that came from the meeting were: expand and diversify testing options (door to door, self testing and male-targeted testing) and make HIV testing a universal agenda. National governments must also provide incentives to promote care and support initiatives for citizens, such as tax exemptions for caregivers, social protection for caregivers and people living with HIV and AIDS (PLWHAs), and micro-enterprise funds targeted at caregivers and PLWHAs. Nutrition should be made part of treatment – both national governments and donors should aim to promote food sovereignty at the household level.
Research conducted by civil society activists in various countries, including Uganda and Zimbabwe, shows that efforts to prevent vertical transmission are failing to reach the very group they were designed for – HIV-positive pregnant women. One of the key reasons for this is that the national programmes have been narrowly focused on providing antiretroviral prophylaxis and not on the other essentials – prevention, counselling, care and treatment for women and children. ‘On paper, the existing global programme is a model of sound design, human rights principles and a comprehensive approach’, the researchers noted. ‘In practice, it is a shameful demonstration of double standards and another instance of women's programming for which everyone and no one at the United Nations is in charge.’ In every country, the researchers found rampant fear of stigma among women and discrimination by health care workers.
Between 2007 and 2008, UNAIDS and the World Bank partnered with the national AIDS authorities of Kenya, Lesotho, Swaziland, Uganda and Mozambique to find out how and where most HIV infections were occurring in each country, and whether existing prevention efforts and expenditure matched these findings. The recently released reports reveal that few prevention programmes are based on existing evidence of what drives HIV and AIDS epidemics in the five countries surveyed. For example, in Mozambique, 19% of new HIV infections resulted from sex work, 3% from injecting drug use, and 5% from men who have sex with men (MSM), yet there are very few programmes targeting sex workers, and none aimed at drug users and MSM. The research also found that spending on HIV prevention was often simply too low: Lesotho spent just 13% of its national AIDS budget on prevention, whereas Uganda spent 34%, despite having an HIV infection rate of only 5.4%.