London, 30 November 2004 — Donor governments and countries hardest hit by HIV/AIDS must take immediate steps to address today’s treatment deficit emergency and the gaps in research and development to fight the pandemic, the international medical humanitarian organization Médecins Sans Frontières urged in a briefing today.
MSF currently provides antiretroviral treatment to more than 23,000 people living with HIV/AIDS in 27 countries in Asia, Africa, Latin America and Eastern Europe. "MSF has succeeded in making a difference to our patients and their families, but we have not seen massive scale-up efforts in most of the countries we work in. Outside the few clinics offering ARVs, the treatment landscape is a desert. The imperative to fund and manage treatment programmes is still being neglected," said Dr Rowan Gillies, president of MSF International.
Out of the six million people needing antiretroviral treatment in developing countries, only 440,000 currently have access to it.
Yet several important lessons about expanding AIDS treatment have been learnt in MSF and other treatment programmes in the past few years enabling sharp increases in patient enrollment. First is the use of simplified treatment regimens. "Although they are not the final answer to AIDS, triple drug cocktails literally allow people to rise from their deathbeds, and live normal, longer lives," said Dr Arnaud Jeannin from MSF’s AIDS programme in Malawi. More than 75% of new patients within all MSF projects start treatment on these affordable one-pill-twice-a-day formulations produced by generic companies. Clinical and biological results have been excellent with overall probability of survival at 85.3% after 24 months of treatment.
Another significant factor leading to good treatment results is the programme design: MSF offers treatment free of charge, and provides support and education to help people take their medicines correctly and consistently. This has led to adherence rates that rival or exceed those seen in the West, a factor considered essential in slowing the onset of resistance.
Overall, the AIDS pandemic remains undefeated. At today’s briefing, MSF also highlighted the lack of paediatric formulations of antiretroviral medicines and the lack of reliable diagnostic tests to detect tuberculosis, the number one AIDS-related opportunistic infection, in HIV-positive individuals. "R&D efforts leading to practical advances in treating the poorest communities most affected by HIV/AIDS should be prioritized as part of a comprehensive response to AIDS," said Daniel Berman, coordinator of MSF’s campaign for Access to Essential Medicines.
MSF’s projects for people with HIV/AIDS
World AIDS Day 2004 Information Document
Despite their proven efficacy, antiretroviral medicines are still not getting to the vast majority of patients living with HIV/AIDS in poor countries.
Thirty-eight million people carry the AIDS virus, the vast majority in the developing world, and almost three million people, including half a million children, died from the disease last year. More than six million HIV+ people worldwide desperately need antiretroviral treatment today, and yet less than 500,000 people presently have access to it.
MSF and AIDS
MSF has been caring for people living with HIV/AIDS in developing countries since the mid-1990s, and the first MSF ARV programmes began in 2000 in Thailand and South Africa.
MSF currently provides antiretroviral treatment to more than 23,000 patients in a total of 27 countries: Benin, Burkina Faso, Burundi, Cambodia, Cameroon, China, Democratic Republic of Congo, Ecuador, Ethiopia, Guatemala, Guinea, Honduras, Indonesia, Kenya, Laos, Malawi, Mozambique, Myanmar, Nigeria, Peru, Rwanda, South Africa, Thailand, Uganda, Ukraine, Zambia and Zimbabwe.
Of these, 1400, or 6%, are children.
MSF AIDS programmes are run in diverse settings ranging from hospitals in the capitals to city slums to remote rural areas and areas hit by armed conflicts, and their aim is to provide a comprehensive package of care to patients. Projects include prevention efforts (health education, prevention of mother-to-child transmission of HIV, condom distribution), voluntary counselling and testing, nutritional and psychosocial support, treatment and prophylaxis of opportunistic infections, and ARV treatment.
In most MSF AIDS programmes, eligibility for ARV therapy follows WHO guidelines. In many projects, the standard way of determining the extent of a patient’s infection, measurement of CD4 cells, is not available and some clinical stage III and IV patients are initiated based on clinical signs alone.
The profile of patients in places where MSF works is significantly different from those in wealthier countries. More than half of all patients treated within MSF programmes are women of childbearing age, and there are high numbers of children in need of ARV treatment. Patients tend to be in very advanced stages of HIV/AIDS before they seek treatment and are often afflicted with one or more complex co-infections, such as TB.
Another characteristic of providing ARV treatment in resource-poor settings is the lack of human resources. Due to AIDS-related deaths, lack of training capacity and difficult working conditions in high HIV-prevalence countries, most countries starting to expand ARV treatment are experiencing shortages of qualified medical professionals.
MSF: Expanding the numbers of people who benefit
The number of patients MSF treats with ARVs has increased rapidly over the past two years. Today, the total is 23,000 patients in 27 countries – an 150% increase compared to December 2003, when MSF was treating 9,000 patients in 22 countries.
The benefits of treatment are clear. Most patients are thriving: their immune systems are stronger, they are gaining weight and able to live fuller and longer lives.
In large part, this rapid expansion of numbers benefiting from treatment is because MSF has sought wherever possible to adapt ARV treatment protocols to poor countries. These “simplification” measures have included:
- Using fixed-dose combination tablets, which mean that patients only need to take one pill twice a day, making it easier to adhere to treatment;
- Introducing simplified inclusion criteria for new patients;
- Training nurses and clinical officers to be more involved in initiating and monitoring treatment; and
- Offering care closer to communities in need, at local health clinics rather than distant district or national hospitals.
As of May 2004, 76% of new patients within MSF projects were starting treatment on the one-pill-twice-a-day regimen. The most frequently used FDC is a triple combination of lamivudine, stavudine and nevirapine, usually sourced from Indian generic manufacturers.
The quality, efficacy and safety of these fixed-dose combinations has been approved by the World Health Organization, and in each country they have been registered for use by the relevant drug regulatory authorities. MSF believes that the WHO’s prequalification project, which certifies the quality of ARVs, should be expanded and strengthened, in order to increase the support it can offer to countries’ authorities.
As a non-governmental organisation, MSF has neither the capacity nor the mandate to provide access to treatment on a regional or national level. This responsibility rests with governments, who will continue to need massive, sustained technical and financial support from international actors. In many contexts, MSF works to support the efforts of governments.
A major challenge, for MSF and for governments, will be to ensure that patients in developing countries can continue to access low-cost, safe, quality ARVs in the face of a variety of threats, including the looming 2005 implementation of the World Trade Organisation’s TRIPS agreement on intellectual property which will likely undermine existing generic production of ARVs, especially from India.