World access to HIV drugs improves
Posted by pozlife on April 21, 2007
Significant progress has been made towards the goal of universal access to HIV drugs, the World Health Organisation (WHO) said in a report issued last Tuesday.
But the report finds that rate of increase has slowed down and there needs to be significant improvements if the majority of people with HIV treatment needs are to get the lifesaving antiretrovirals by 2010, as promised by the G8 international leaders’ meeting last year.
The WHO highlighted Africa, the world’s hardest-hit continent, as the place where treatment has improved most dramatically. In fact Africa’s HIV positive people are now more likely to have access to treatment than people in most of Asia, Russia or the middle east.
However the agency said that significant gaps remain.
Treatment for children lags behind treatment for adults; the provision of drugs to pregnant women to stop kids getting HIV in the first place remains scandalously patchy; TB programmes are missing the chance to detect HIV in their patients and co-treat them; and some groups such as intravenous drug users are missing out on the treatment bonanza, especially in Russia, the country with the biggest needle-driven outbreak.
HIV testing needs to be improved, too, says the report; at present in Africa’s hardest-hit countries fewer than one in four HIV positive men, and fewer than one in six women, know their HIV status and only one in nine adults have taken a test.
The report contains a couple of surprises too. More women than men are getting HIV drugs in the majority of countries. And although the average price of the cheapest drug regimens has continued to decrease in the last year, in hasn’t done by much, and in the case of the regimen with the fewest side effects, the average price has actually gone up.
In 2006 over two million people in the developing world were on HIV treatment plus another 600,000 in the developed world, and 700,000 got the drugs for the first time last year.
In Africa 28% of people who need HIV pills now get them, a 65% increase in a year and a 13-fold increase since 2003. in Botswana over 90% of people who need the drugs get them and in Rwanda and Namibia over 70%.
Coverage remains poor, however, in Nigeria, Africa’s biggest country, with only 10% who need treatment getting it.
In Latin America 72% of people who need treatment now get it; although there is variation between countries, the WHO comments that “the overall coverage appears to be approaching universal access”.
However in south and south-east Asia fewer than one in five people who need treatment get it; this is largely driven by the situation in India where at most 9% and possibly as few as 4% of HIV patients are getting the drugs they need. In contrast Thailand and Cambodia now have over 80% coverage.
In eastern Europe and central Asia the position is even worse, with only 15% coverage in the region as a whole and, scandalously in what is now a rich country, only 3% in Russia.
The Russian situation is largely driven by stigma against drug users, who form 87% of people with HIV but only 8% of the 3% who get antiretroviral therapy – this means only one in 400 drug users with HIV is on treatment.
The poorest-served area is north Africa and the middle east, where only 6% of those who need treatment get it. Although this is a low prevalence area for HIV, there are growing epidemics amongst drug users in Libya and Bahrain and the beginnings on one amongst gay men.
Although in most cases equal proportions of men and women get treatment, where they don’t, the situation tends to be biased against men. Worldwide 48% of people with HIV are women but they represent 57% of those getting treatment.
In South Africa while 58% of people with HIV are women, 70% of those who get treatment are; in China, women form 28% of the positive population but 45% of those on treatment.
This may be because women get the opportunity to be tested and treated in antenatal care.
Dr. Charlie Gilks, the head of WHO’s HIV treatment department, told reporters in Geneva that “The encouraging progress that was made . . . has been sustained.” He said that one of the main reasons for the success is the significant drop in the cost of drugs.
However there are ominous signs that prices may not drop much further. Prices of the four cheapest combinations only fell between 10% and 20% last year, and the cheapest combos also tend to be the ones that cause the worst side effects, as they contain d4T (stavudine), a drug that has fallen out of favour in the rich world because it causes fat loss.
The average price of the WHO-approved combination that causes the fewest side effects, AZT/3TC/efavirenz, has actually increased by nearly 40% in the last two years.
Treatment when in is accessed is generally as successful as it is in the rich world; surveys have shown that 80% of people are still on their first drug combination after a year and 75% after two years, with slightly higher failure rates than in the west largely driven by the fact that people are often more ill when they start treatment.
However the price of second-line therapy is still way beyond the pockets of most countries. While the cheapest combination costs $123 a year in the poorest countries and $145 in middle-income ones, the most frequently-used second-line therapy, ddI/abacavir/Kaletra, costs $1,698 in poor countries and $4,735 in middle-income ones.
The recent row between the Thai government and drug company Abbott over the price of Kaletra shows that some arm-twisting negotiations over the price of the second-line Protease Inhibitor drugs will be necessary if treatment success is to be sustained.
It needs to be, because the bottom line is that it’s starting to work. In Botswana, where 30% of the population has HIV and 95% of those who need treatment get it, mortality peaked in 2003 with one in 166 citizens dying every year compared with one in 500 in 1994.
In 2006 this had declined to one in 220 and the upward life expectancy seems to be accelerating.
Global HIV treatment, long thought to be impossible, may now be a realistic hope, and with it may come the first real reductions in the global toll of AIDS.