Times Publications

NEW SCIENCE AND BEST PRACTICE

Earlier treatment with newer drugs has significant resource implications at a time when the Global Fund indicates a $4bn funding gap in 2010, adding further to worries about how the global financial crisis will affect universal access. Although the cost of ART itself remains a significant barrier to recommending treatment initiation earlier, there are also concerns about the cost of CD4 counts and other laboratory tests, as well as the extra personnel required to deliver the treatment.

Yet experience tells us that as awareness of improvements in HIV treatment and care reaches the people who need it, so demand will grow, and it may well require grass roots advocacy to force national Governments and donors to find solutions to these complex issues.

The 15th International Conference on AIDS and STIs in Africa (ICASA 2008) held in Dakar in December 2008

SECOND-LINE TREATMENT
Similarly, the pressure to ensure Africans have access to viral load testing - the most important diagnostic tool in high-income countries for monitoring treatment success – is growing.

One of the most important ART studies has come from Malawi, where CD4 counts and clinical symptoms are used to assess treatment response, because routine viral load tests remain too expensive. It found that as first-line treatment failed, drug-resistant mutations emerged that could severely compromise second-line regimens, and that viral load monitoring would have detected treatment failure earlier, preventing the emergence of many of these mutations.

Currently around 10 per cent of patients on first-line ART need to switch to second-line ART due to treatment failure. Second-line ART, which includes the protease inhibitor class of anti-HIV drugs, costs significantly more than first-line agents, and the wide-scale emergence of resistance threatens their future usefulness.

A 2008 consensus statement by the WHO, the IAS, the World Bank and the Global Fund underscored the need to prioritise research to address two concerns raised by this study - determining the optimal time and criteria for switching to second-line ART, and defining the most appropriate use of viral load and CD4 monitoring in resource-constrained regions.

The answers to these questions will be key in shaping the “second wave” of ART rollout and the clinical approach to treatment and care in low and middle-income countries.

TASK SHIFTING
Delegates described how this “second wave” would not be sustained unless human resource capacity increases, since HIV programmes in Sub-Saharan Africa continue to face a critical shortage of health workers alongside wider problems with health care infrastructures.

Task shifting - transferring certain physician responsibilities to other health workers - emerged as an important strategy for dealing with this acute health care worker shortage and several studies presented at ICASA 2008 demonstrated the impressive health system efficiencies achieved by using nurses or other health care providers to deliver HIV treatment and care.

One modelling study estimated that, as a result of task shifting, the reduced number of physicians needed to provide ART in Rwanda by the end of 2008 would lead to a 78 per cent decline in physician demand for HIV care and a 183 per cent gain in physician capacity for non-HIV care. And Médecins Sans Frontières, working in Malawi’s rural Thyolo district, were able to treat all 13,000 individuals who urgently required ART by shifting some counselling work from nurses to lay counsellors and then shifting ART initiation duties from physicians to nurses.

Although concerns were raised about service quality and protecting patient rights, most presentations suggested that task shifting did not adversely affect quality of care, and in some cases, even improved it. Since it takes much less time to train a lay counsellor, or even a nurse, than a physician, the question now is not whether this strategy works, but how to make it work. To help provide these answers task shifting guidelines have now been developed by the WHO, in collaboration with UNAIDS and PEPFAR. THE ROLE OF BUSINESS
ICASA 2008 heard many examples from across Africa how workplaces can become centres of hope and effective entry points in order to achieve universal access. For example, the Federation of Kenyan Employers is encouraging CEOs to be tested for HIV as a way of generating more support for voluntary testing and counselling within their own companies; Rio Tinto is making its health facilities available not just to employees but also to the local community in partnership with the Government of Cameroon which supplies free anti-HIV drugs; and the Hygeia group is developing a community-based insurance scheme for market women in Nigeria’s Lagos State that gives them secure access to health services.

At a satellite session entitled “Working towards a comprehensive private section response at a national level” a consensus emerged, reflected in a subsequent declaration, that the private sector must work closer together to deliver a coherent and comprehensive response to HIV/AIDS. The reduction in international aid due to the global financial crisis makes pubic-private partnership building even more vital.

African businesses can – and must – play their part by delivering essential HIV/AIDS information to their employees; supporting testing, treatment and care; and creating a favourable, non-discriminatory environment to help sustain these efforts. | << back to previous page