Durban 2000 to Toronto 2006: The evolving challenges in implementing AIDS treatment in Africa

Introduction The Durban AIDS Conference in 2000 is a landmark in the global response to the AIDS pandemic. As the first International AIDS Conference held in Africa and the developing world, it created a unique juxtaposition between scientific advances, community aspiration, global inequity and stark reality of one of the worst affected areas in the world. With its inescapable political pressure, it ‘broke the silence’ resulting in the birth of a social movement with a common purpose and vision for affordable AIDS treatment [1]. The Durban AIDS Conference changed the discourse from ‘whether’ to ‘how’ to provide antiretroviral therapy (ART) in resource-constrained settings, especially Africa. On the eve of the Toronto AIDS conference, it is opportune to take stock of the challenges in AIDS treatment access, particularly in light of the significant resources made available by the Global Fund to fight AIDS, Tuberculosis and Malaria and the President's Emergency Plan for AIDS Relief. Since the Durban AIDS Conference, the collective efforts of activists, researchers, service providers, pharmaceutical companies, policy makers and international agencies have generated real momentum in scaling up AIDS treatment and prevention across the globe, with special emphasis on Africa. Coverage of ART in the developing world has more than doubled – increasing from 400 000 in 2003 to approximately 1 million by June 2005 (Table 1) [2]. While still short of the WHO goal of ‘3 by 5’, the momentum in expanding treatment access is a remarkable achievement despite the initial challenges in implementing AIDS treatment programs, especially in Africa where the burden is largest, which included the costs of the drugs, concerns about adherence, and inadequate infrastructure for laboratory monitoring.Table 1: Estimated number of people receiving antiretroviral therapy (ART) and per cent coverage in 10 sub-Saharan countries with the highest unmet need by June 2005.Affordability of ART, which was the rallying point at the Durban conference, is no longer a major stumbling block to treatment access. There have been drastic declines in the price of first line antiretroviral drugs for adults, e.g., in South Africa, Efavirenz, lamivudine (3TC) and Stavudine (d4T), three commonly used first line agents, cost $568 (R3411) per month in 2000 compared to the current price of $51 (R307) per month. At this price, it is comparable and often cheaper, than the cost of drugs for chronic diseases such as hypertension, asthma and diabetes. The costs of paediatric treatment as well as second and third line drug regimens have been coming down recently but are still relatively high. As demand for these increases, it is hoped that the larger volumes would also make these affordable. It is widely accepted that good adherence to ART is fundamental to treatment success while inadequate adherence has a poor clinical prognosis and poses the public health hazard of drug resistance. The concerns about adherence in Africa, which emanated from pre-conceived notions about low education and literacy levels and knowledge of timekeeping, have been shown repeatedly to be unfounded by ART rollout programmes in the resource constrained settings such as Malawi [3], South Africa [4] and Uganda [5] which have all reported very high adherence levels. Importantly, the programmes have implemented innovative strategies to improve adherence including once-a-day regimens, minimizing the number of pills, avoidance of food precautions, fitting the antiretroviral drugs into the patient's lifestyle, and involvement of relatives, friends and/or community members in support of the patient's adherence [6]. A major advance in easing the burden of laboratory monitoring is the widespread availability of rapid HIV tests. Since specialized costly equipment is needed to perform CD4 cell count and viral load assays, these tests are not as readily available and remain expensive. Alternative approaches to laboratory monitoring of ART with white blood cell counts and clinical status are used to supplement the sparing use of these expensive assays. Indeed, the costs of the laboratory monitoring assays are rapidly replacing the costs of drugs as the major economic impediment to ART access. In South Africa, AIDS denialism and irrational resistance to ART which persisted at the highest political echelons, pervaded the Durban AIDS Conference, which was also the venue for the launch of the Durban Declaration [7]. However, in a major turnaround, the South African government decided on 8 August 2003, to make ART freely available in the public health sector; a defining moment in the country's response to the AIDS epidemic. By June 2005, the number of people on ART in South African public health services had risen from a handful to approximately 130 000 and a total of 214 health care facilities around the country are currently offering ART [8]. As ART is being scaled up, health care services in Africa are struggling to cope with the additional burden of care; the biggest challenge being the shortage of skilled health care personnel. Africa has been struggling for years to retain its skilled health professionals. Medical practice in Africa is now dominated by AIDS. The ever-increasing queues of AIDS patients results in overworked and stressed staff, concerns about accidental HIV exposure and lowered morale [9]. While accurate data on the true extent of the medical ‘brain drain’ are not available, a study undertaken by the University of Witwatersrand in Johannesburg, South Africa showed that over the last 35 years, 44.1% of their medical graduates have emigrated [10]. The crisis in the sustainability of health care provision, buckling under the additional demand for AIDS care, is compounded by the intensive one-on-one approach to voluntary counselling and testing (VCT). The expansion of AIDS care is being hampered by the bottleneck created by the inability to implement large scale VCT. Rapid expansion of ART provision necessitates a re-think in the paradigm of VCT provision and countries like Botswana are implementing alternative approaches, such as ‘opt-out’ testing [11]. Not only does VCT enhance prevention, it serves as an entrée to treatment and care and has been shown to be cost effective [12,13]. Eminent human rights proponents have argued for a move away from the ‘HIV exceptionalism’ approach to a ‘HIV normalization’ approach wherein HIV is treated as an infectious disease for which early diagnosis is essential [11,14]. While the various practical and political challenges in ART provision have changed over the last 6 years, two over-arching challenges, the persistence of stigma and the failure to integrate prevention into care, continue to hamper the effort to maximize the benefits of ART implementation in Africa. Stigma and discrimination have long obstructed efforts to contain the spread of HIV [15,16] and remain obstacles to treatment access. Further, stigma is a common cause of poor ART adherence when patients, particularly women, have to take their tablets surreptitiously due to non-disclosure of their HIV status to partners, family and household members. The concern that poor adherence will lead to increases in therapeutic failure rates, multi-resistant HIV, and rates of switching to more expensive drug regimens, is an ever-present threat. While provision of AIDS care creates opportunities for improving prevention efforts there have been few successful sustained efforts [17] to integrate prevention into care programs. Prevention messages have traditionally concentrated on protecting those at risk of infection. New models which refocus prevention messages to target those already infected, are emerging. Such models of prevention in care settings extend beyond the mere distribution of condoms at AIDS treatment clinics to comprehensive prevention programmes and messages specifically targeting the role of infected individuals in containing the spread of HIV. Twenty five years since the discovery of HIV, as we gather at 2006 Toronto AIDS Conference under the banner ‘Time to deliver’, we need to once again find ways to re-commit ourselves, as scientists, community activists, health service providers and policy makers, to our common purpose of addressing the evolving challenges in making AIDS treatment access a reality for all. Acknowledgements CAPRISA is supported by the National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), US Department of Health and Human Services (Grant #U19AI51794). The author leads an AIDS treatment Programme in South Africa that is funded by both the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and the President's Emergency Plan for AIDS Relief (PEPFAR).

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