The ARV Scale Up

With so much going on, I haven't gotten around to what is probably the biggest thing going on here, which is that there is an official quasi-commitment on the part of UNAIDS, the Global Fund, B&M Gates, the WHO, and the rest of the gang, to provide global access to HIV treatment by 2010. I say quasi because UNAIDS is being weaselly about it, and also because I'm not sure that even the most impassioned advocates really believe it is possible.

First a word about antiretroviral drugs. On the one hand, they are miraculous. It used to be a legitimate position that doctors tended to overtreat and that what with the side effects and the expense and all, it would be best to wait until people were manifestly sick before prescribing them. It's becoming clear now that people do better in the long term if they start earlier, based on CD4+ cell counts, with the latest guidelines calling for starting at 350 cells/ml. Unfortunately, in most of the world, people don't have access to these tests. In fact, few people present for treatment who aren't already sick, and have T-cell counts that are much lower than that. The point of all this is that there are different ways of looking at the global need.

Right now, about 3 million people worldwide are on ARV treatment, which means that 40million people with HIV are not. However, they don't all qualify for immediate treatment. If we use current criteria, we'd need to get 7 million more people on treatment today to meet the official need. If we use the guidelines in place in the wealthy countries, we'd need to treat 10 million more. But all of those 40 million+ will need treatment eventually, and meanwhile, there are 2 to 3 new infections for every additional person who receives treatment, in other words, we're falling further and further behind.

What happens when people don't get treatment? They die a horrible, slow death. What happens when they do get treatment? Most people can live an almost normal, healthy life. You need a little bit of luck. There are side effects which are worse for some people than for others, and treatment interruptions can produce resistant virus and treatment failure. Nevertheless, it has been proved beyond doubt that even in the poorest places on earth, it is possible to successfully maintain people on ARV therapy and that they can then resume productive lives. So there is an obvious moral imperative.

The cost of regimens used currently is about $95/year per person, but second line regimens for people who fail their initial treatment are more expensive. Some people argue that providing universal AIDS treatment takes money away from building comprehensive health care systems and combatting other diseases, but there is another way to look at it. The effort to provide universal HIV treatment has stimulated the development of health care systems where no other need or cause has done so before. The challenge is to integrate all the essential efforts that have to be made to address the severe public health needs of the poor. These needs are not in competition with each other, they are a single problem.

Right now there's a demonstration going by -- in fact they're stepping over my legs as I sit against the wall -- against extending drug patents for second line drugs. That's a key part of the challenge, getting drug costs down so that the scale up of universal treatment is feasible. Drug companies want to make their billions from consumers in the wealthy countries and they're afraid that selling drugs more cheaply to poor countries will interfere with that noble objective.

There are many other political and technical complexities to this problem, but I think I've given you the pistachio shell summary. The stories of near death and resurrection when people get access to these agents are as moving as any human stories can be. They really are a triumph of biomedical science, for all their shortcomings. And their existence sharply delineates the ethical quandary of our planet.