Treatment works
Advocacy brief
THE CHANGING FACE OF HIV/AIDS
The two photographs above show how the history of HIV/AIDS
is changing. Joseph Jeune is a 26-year-old peasant farmer
in Lascahobas, a small town in central Haiti. When the first
picture was taken in March 2003, his parents had already
bought his coffin. Suffering from the advanced stages of AIDS,
Joseph Jeune probably had only weeks to live. The second
picture, taken six months later, shows him 20 kg heavier
and transformed after receiving treatment for HIV/AIDS
and tuberculosis co-infection.
Joseph receives care in the small clinic in his home town. The
clinic’s HIV/AIDS and TB treatment programmes are part of a
wider initiative to strengthen the health service infrastructure
across much of Haiti’s central plateau. The effort involves
nongovernmental organisations, the public sector and communities,
with major support from the Global Fund to fight AIDS,
TB and Malaria. Using antiretroviral therapy as an entry point,
the programme is building up primary health care in communities,
for a total population of about 260 000 people. It does so
through improved drug procurement and management, the
expansion of HIV counselling and testing, increased salaries
for local health care personnel and the training of numerous
community health care workers. Primary care clinics have been
refurbished, restocked with essential medicines, and provided
with new staff. They are receiving ten times more patients for
general medical care daily than before the project began.
Projects like this can bring the medical treatment that saved Joseph Jeune to millions of other people in poor and middleincome
countries and how, crucially, such efforts can drive
improvements in health systems.
BRAZIL SHOWS THE WAY
Brazil has the most advanced national HIV/AIDS treatment programme
in the developing world. By mid-2002, the programme had
115,000 participants. It is estimated that between 1994 and 2002,
almost 100,000 deaths have been averted in Brazil (a 50% drop
in mortality) through the introduction of ART.
As a result of this programme, there has been a significant decline
in the number of hospital admissions. Cost savings in reduced
hospital admissions and opportunistic infections are estimated at
more than US $ 1 billion. The programme has also been effective
in reducing the rates of TB and other opportunistic infections.
The viability of the Brazilian HIV/AIDS programme, including
treatment distribution, owes much to effective social mobilization,
including representation of affected communities in government,
non-governmental organizations, and other fora. The distribution
of free antiretrovirals in itself prevented the problems associated
with black market or substandard regimens.
ANTIRETROVIRAL THERAPY IN THE WESTERN CAPE PROVINCE, SOUTH AFRICA
South Africa’s first public sector project offering ART was established at community health centres in the Cape Town township
of Khayelitsha, where clinics began treatment in May 2001.
By June 2003, over 5000 patients had enrolled and over 600
children and adults had started treatment. The costs of drugs, viral
load tests and the wages of half the clinical staff have been met by
Médecins Sans Frontières; the remaining costs have been covered
by the provincial government.
Adherence, survival and virological success in this project are
comparable to if not better than those in many settings in wealthier
countries. The potential to treat families in one primary health
care setting, to connect with community-based support groups
and nongovernmental organizations, and proximity to referring
services all contribute to impressive clinical outcomes.
The province is attempting to bolster the entire primary care
system in tandem with the delivery of ART. Primary care services
are benefiting from the strengthening of referral systems with
hospitals, the provision of clinical support by specialists, and the
increased emphasis on drug availability. Nurses with no formal
training in diagnostics and curative care have rapidly become
competent primary care clinicians through training and mentoring
in HIV/AIDS care. Increased resources (both human and financial)
have been directed at primary care as a result of the work of these
projects. There has been a reinvigoration of clinical support networks,
increased uptake of a range of services including voluntary
counselling and testing, and more openness about HIV/AIDS.
CAMBODIA AND THAILAND – SUCCESSES AND CHALLENGES
HIV infection in Asia remains largely confined to those people at
higher levels of risk – sex workers, injecting drug users, men who have sex with men – and their sexual partners. Those at elevated risk
represent anywhere from 7% to 25% of the adult population, making
severe epidemics a possibility in all the countries of the region.
However, the focused nature of risk means in turn that focused
nature of risk means in turn that focused prevention efforts with
high coverage can slow or reverse the course of the epidemics.
By mounting intensive, well-funded and extensive efforts to reduce
the risks in sex work, Cambodia and Thailand have changed the
course of their epidemics. In both countries, the role of sex work
in HIV transmission was realized early on and major nationwide
prevention efforts were mounted, working not only with brothel
owners and sex workers, but also reaching out to the large client
populations – almost 20% of adult males in the early 1990s. In
response to these programmes, condom use between sex workers
and clients rose to more than 90% and the number of men visiting
sex workers was halved.
Using this Asian Epidemic Model, the East West Center and its collaborators have explored the impacts of these prevention
programmes. Without aggressive prevention programmes it is
estimated that both countries would now be looking at expanding
epidemics with 10 – 15% of their adult populations living with
HIV/AIDS, instead of the declining epidemics of 2-3% currently seen.
But as one avenue of HIV transmission is closed off, others appear.
Programmes for injecting drug users (IDU), men who have sex
with men, and sexually active young people have been weak and
ineffective to date. The epidemic among injecting drug users in
Thailand continues unabated, condom use among young people
remains low at around 20% and there are HIV levels of around 15%
in men who have sex with men. If the two countries are to sustain
their past successes they must adapt responses to be as effective
and aggressive with new evolving patterns of risk.
PREVENTION AND TREATMENT IN BRAZIL AND THE BAHAMAS
The Brazilian experience shows that scaling up antiretroviral
treatment enhances, rather than impedes, prevention efforts
if they are scaled up simultaneously. Since 1996 (the year
Brazil’s universal antiretroviral drug distribution programme
began), sexual behaviour, and more recently HIV prevalence,
have been monitored among nearly 30 000 army conscripts.
In 1999–2002, over 80% of the conscripts were sexually
active and the proportion with multiple partners remained
steady; but HIV prevalence among the men was low (0.08%)
and condom use was high and increasing. In 1999, 62% of men
reported condom use at last sexual intercourse, and in 2000
and 2002 70% did so. Condom use with a paid partner in the
previous year increased from 69% to 77% in 2002.
The impact of prevention interventions was also observed among IDUs. The most significant reduction in the index of
sexual risk behaviour was found in the group.
Similarly in the Bahamas, the introduction of ART has been accompanied by heightened prevention successes, in addition
to significant reductions in deaths (56% reduction in deaths
from AIDS, including an 89% in deaths among children). The
success of prevention efforts is also evident from the fact that
mother-to-child transmission of HIV was reduced from 28% to
3%; there was also a 44.4% reduction in new HIV cases, a 41%
decline in HIV prevalence rate among patients being treated
for sexually transmitted infections, and a 38% decline in HIV
prevalence rate among pregnant women.
All information is taken from The World Health Report 2004: Changing History.