World HIV treatment making progress, but domestic AIDS agenda floundering

Funding cuts could make everything worse

The annual HIV/AIDS progress report by the World Health Organization (WHO) shows heartening progress in the worldwide battle against the pandemic.

New HIV infections have been reduced by 17% since 2001, according to the 2009 AIDS Epidemic Update. And the number of new infections in the world's hardest hit region, sub-Saharan Africa, has declined by 15%.1

Another study focuses on HIV transmission rates and finds that the global HIV transmission rate dropped by 19.6% between 2001 and 2007, suggesting some success in global HIV prevention efforts.2

"Most of our progress is in sub-Saharan Africa where there were 400,000 fewer new infections in 2008 than in 2001," says Paul De Lay, MD, deputy executive director of the Joint United Nations Programme on HIV/AIDS (UNAIDS). De Lay spoke at an international media teleconference, held by the World Health Organization (WHO) and UNAIDS, to discuss the 2009 AIDS report.

"This is a sign that our efforts are making a difference," De Lay says.

The 2009 report also highlights the fact that 2.9 million lives have been saved globally because of antiretroviral drugs and greater access to ART worldwide, says Teguest Guerma, MD, acting director of the HIV/AIDS department at WHO. Guerma also spoke at the media teleconference on the 2009 AIDS report.

"AIDS-related deaths declined by over 10% in the past five years," Guerma says. "For example, in Kenya, AIDS-related deaths declined by 29%."

These declines are attributed to increased access to ART. The 2009 AIDS Epidemic Update noted that 4 million people in low- and middle-income countries were receiving antiretroviral therapy, a 10-fold increase over five years. Globally, new HIV infections peaked in 1996 when an estimated 3.5 million people were newly infected with the virus. This compares with an estimated 2.7 million new HIV infections in 2008, representing a 30% decrease.

While noting these positive trends, the latest AIDS report discusses gaps in prevention approaches and cautions against complacency.

"We're strongly advocating we don't let treatment programs diminish in any way," De Lay says. "We want to scale up for people who need it because the numbers are clear that only through prevention can we turn this epidemic around."

AIDS activists have been less diplomatic about what's needed.

On World AIDS Day, Dec. 1, 2009, activists from ACT UP Philadelphia, Health GAP, DC Fights Back, and others groups protested at the White House and the Wilson Building in Washington, DC, against what they called a flawed course in HIV policy by President Barack Obama's administration and the Washington, DC, city government.

According to a recent study, an estimated 3% of adults in Washington, DC, are infected with HIV, a prevalence rate that is comparable to some sub-Saharan African countries.3

Global AIDS groups gave Obama a D+ score for his failure to deliver on promises to increase HIV/AIDS funding.

Their chief concerns center around proposed flat-funding for global AIDS initiatives and Washington, D.C.'s epidemic's problems.

Also, the ADAP Advocacy Association called on Obama and the U.S. Congress to stop with "fancy proclamations" and provide an emergency supplement of $268 million to the AIDS Drug Assistance Program (ADAP).

All that has been provided so far by Congress is a token $20 million increase to ADAP, despite a drug waiting list that has increased by more than 800% since January, 2009, says Bill Arnold, director of the ADAP Working Group in Washington, DC.

As of World AIDS Day, nine states had lists of people waiting to receive ARTs through ADAP for a total of 342 people living with HIV/AIDS.

"We are starting to advocate right now for additional money, and the impetus for that will have to come from the White House, either through emergency federal funding or stimulus funding or returned TARP funding," Arnold says.

"It's not like we need billions of dollars, but it's clear we need hundreds," Arnold says.

States have cut $167 million from AIDS programs in the past year, and the federal commitment to ADAP also has fallen as a percentage of the total funds, according to a December ADAP report.

For instance, in 2000, federal funds accounted for 72% of ADAP funding, and now the federal share of ADAP funding is only 54%. The difference is made up by states, drug company rebates, private money, and other funds, Arnold says.

Recent surveillance data from the Centers for Disease Control and Prevention (CDC) of Atlanta, GA, suggest that more than 1.1 million Americans are living with HIV infection, as of 2006, and 21% of these adults and adolescents are undiagnosed.4

Even as the number of Americans living with HIV/AIDS increases, as new infections increase, and as increasing numbers of people lose private insurance and need assistance to pay for their antiretroviral drugs, ADAP's funding has remained flat, Arnold says.

"What we're really getting caught up in here is the people who need the service are living longer, and the basic population is swelling, and the resources have not kept track," Arnold explains.

A decade ago, ADAPs had fewer people who needed the drugs, and the formularies were more limited. Now people with HIV/AIDS routinely are living into third and fourth decades of being infected, and they'll need ART every day of those longer lifetimes, Arnold says.

Also, HIV drugs are expensive, although ADAPs pay less than most entities, Arnold says.

An antiretroviral drug regimen for HIV typically costs patients $1,000 a month, he adds.

"The other exacerbating factor is that many states that used to be able to chip in some money for ADAPs now are in deep trouble fiscally and can't get their budgets passed," Arnold says.

The list of troubled state ADAPs is growing longer with Tennessee being one of the latest states forced to start an ADAP waiting list, Arnold says.

"California already is embroiled in discussions of cutting their ADAP, and California represents close to 20% of the U.S. AIDS epidemic, so if California's ADAP collapses, it's trouble," he says.

Ohio, Arizona, Indiana, Mississippi, and Washington state also are close to having major problems funding their ADAPs, he adds.

Arnold, like other AIDS advocates, thought the nearly decade-long trend of flat-funding for domestic HIV/AIDS programs would be reversed in 2009 when Democrats led Congress and the White House for the first time in nearly two decades.

"It is past time for those who represent the people who are disproportionately affected by this epidemic to storm the ramparts," Arnold says. "I was surprised a Democratic Congress didn't give ADAPs more money."

It's understandable that the White House is focusing on health care reform and has been reluctant to wade into specific details, including ADAP funding, but the problem of ADAP waiting lists is growing, Arnold notes.

"I think whether or not the economy improves, you can't be sacrificing these people just because bonuses on Wall Street might have to be cut," he adds.

International AIDS prevention and treatment programs also need additional funding, world health officials say.

While the international AIDS report shows a positive trend, international health officials and HIV/AIDS activists warn that all of the progress made could be reversed if the U.S. and other nations reduce their financial support, particularly as the international economic crisis takes its toll.

"We've been analyzing the impact of the economic crisis for the last year," De Lay says.

"Particularly we're looking at how it affects AIDS response, prevention, and treatment," he adds. "And what we've seen is that most of the impact has been in middle-income countries in their domestic budgets."

There's been more of a delay in impact to international funding, but the impact of declining funding assistance is expected to play out in 2010, he says.

For the domestic AIDS epidemic, nearly all of the success is in the treatment arena. While there are many proven prevention methods, and a national strategy of the past eight years of targeting people who are infected with prevention interventions, these appear to have little impact on new infections in the U.S.

"Most people would say, and I would say that the problem is the lack of a highly visible national HIV prevention program for almost a decade," Arnold says. "The hard to reach communities and younger generations coming along year after year, well if they haven't been reached with a prevention message, then guess what? As STD rates go up then HIV rates go up."

References

  1. UNAIDS 2009 AIDS Epidemic Update. Annual report published at www.unaids.org by UNAIDS/WHO. 2009:1-100.
  2. Holtgrave DR. Apparent declines in the global HIV transmission rate. Int J STD AIDS. 2009;20(12):876-878.
  3. Greenberg AE, Hader SL, Masur H, et al. Fighting HIV/AIDS in Washington, D.C. Health Aff (Millwood). 2009;28(6):1677-1687.
  4. Campsmith ML, Rhodes PH, Hall HI, et al. Undiagnosed HIV prevalence among adults and adolescents in the United States at the end of 2006. J Acquir Immune Defic Syndr. 2009;Epub ahead of print.