Special Report

Global HIV Perspective Suggests a Long Way to Go

The challenge facing the global community is to immediately marshall sufficient resources to ensure rapid scale-up of life-saving prevention strategies. — Global HIV Prevention Working Group 2003

Not long ago at one of the Biannual World AIDS Conferences in Geneva, the topic of global HIV perspective was a colorful Bridging the Gap. Now 5 years later, the time has come to close that gap. To do that, a Global HIV Working Group has provided a region-by-region analysis to specify the gaps and recommend recovery measures. The major finding is that spending from all sources in 2002 was $3.8 billion short of what will be needed in 2005.

The findings of the working group are very, very sobering. But they believe the worst-case scenario is avoidable. The approach to make it avoidable consists of substrategies that are targeted at 5 global regions: sub-Saharan Africa, Asia and the Pacific, Eastern Europe and Central Asia, the Caribbean and Latin America, and North Africa and the Middle East.

It is beyond my scope to summarize all the regional strategies but here are some high points.

  • More than 40 million people are infected with HIV worldwide. Epidemiologists grossly underestimated a decade ago how broadly the epidemic would spread.
  • China and India lean on the brink of widespread pandemonium.
  • In the former Soviet Union, many risk factors will threaten millions in those risk groups.
  • In sub-Saharan Africa, only 6% of people have access to voluntary counseling and testing.
  • In Asia and the Pacific, only 10% of drug infectors benefit from harm reduction.
  • In Eastern Europe and Central Asia, drug infection is a widespread risk factor.
  • In North Africa and the Middle East, there are extremely limited harm-reduction programs; only about 5% of sex workers have programs to help them and their clients avoid HIV.

The funding gap is huge and the discussion of the billions needed to curb the epidemic worldwide is a focus of the working group. In 2002, $1.9 billion was spent worldwide. A total of $5.7 billion is needed in 2005, so the gap is $3.8 million. More deplorable, in 2002 in Eastern Europe and Central Asia, only $23 million was spent. By 2005, $1.2 billion is needed. These figures are now confidence inspiring.

The concept of combination prevention pervades the strategies of the working group: volunteer counseling and testing (VCT), programs for injecting drug users, application of effective antiretroviral therapy, STD control, prevention of mother-to-child transmission, guaranteeing a safe blood supply, applying standard infection control practices, and policy reforms including legalization of the sale of syringes without a prescription and mandating condoms in brothels.

There are models of success in these measures to quell spread and minimize morbidity. In South Africa, condom distribution increased from 6 million in 1994 to 358 million in 2002. In Zimbabwe after peer-based HIV/AIDS education entered factories, there was a 34 percent reduction in new infections. In the Ivory Coast, the government has asked all businesses with more than 50 employees to establish committees for HIV/AIDS.

The Ugandan experience is unique in its success. President Yoweri Museveni since 1986 has led an unprecedented battle to curb HIV, and he did it by enlisting national stakeholders, including faith-based groups, to fight the disease. Who says that sexual mores cannot be altered in such countries? Look at the rates of sexually active 15 year olds—nearly 50% in 1991 in Uganda but less than 25% by 2001. Indeed, the result has been that prenatal rates have fallen in Kampala from 30% to 11.3% since 1992. Clearly, the empowerment of women and girls is a centerpiece in changing the HIV scenario in sub-Saharan Africa. Easier said than done in regions where women often cannot own or inherit their own land and where 80% contract the virus from their partners.

When we consider Asia and the Pacific we see success models: the 100% condom policy in Thailand, a multisectoral strategy in Cambodia, empowerment of sex workers in Bangladesh, and STD control in India. These successes are hardly sufficient. For starters, $1.48 billion additional annual spending will be needed in 2005. In this region also there is—a strange term evolves—a condom gap. There is a condom access gap, a condom promotion gap, a condom resource gap, and a condom effectiveness gap. Clearly, the world needs to help these countries emerge with much better condom policies.

In Latin America, Brazil is the only real success story. In Brazil, prevention as well as treatment initiatives have enabled the country to have a marked reduction in HIV. In another arena, Brazil has made it possible for up to 60% of intravenous drug users who participated in government harm-reduction programs to have their own injection equipment.

North Africa and the Middle East may be the most challenging region in terms of social acceptance of HIV programs. Witness that only $23 million in 2002 was spent on HIV/AIDS. Middle Eastern government would benefit from modeling programs in North African countries like Morocco, where there are 30 community-based projects. Morocco found how to use funds from the Global Fund to Fight AIDS, Tuberculosis and Malaria to scale up these programs.

It was reassuring to see that the working group did not leave the need for research out of their analysis. Target areas will require "substantial new resources . . . for new prevention tools" to expand the work in vaccines, microbicides, antiretroviral therapies, female barrier methods, circumcision, and STD control.

The working group studied the source of funds to fight HIV. From where are all these billions to come? The developing countries themselves actually account for over 30%. Bilateral donors account for another 30%. The rest come from foundations, the United Nations, and the World Bank. It is interesting to look at select donor countries. Who does the most? Among developed countries and based on giving as a share of national revenues, the UK, Norway, Holland, and Canada outrank the United States. France is last. The working group met as the current Bush Administration in the United States declared that the United States would spend $10 billion to $15 billion over the next 5 years, a seemingly huge number compared to the $514 million it produced in 2002. Yet, even though the figure for prevention needs is $5.7 billion in 2005, the figure for care and support is $5.5—figures that rise to $6.6 billion and $8.7 billion, respectively, by 2007. Clearly billions of currency will be needed beyond the US commitment.

The final recommendations of the working group run the lines that have been summarized above and include:

  • increased global spending;
  • prevention scale up;
  • immediate scale up of tactics already proven effective;
  • emphasis on new initiatives to reflect a continuum of services;
  • dedication by donor countries to partner with multilateral agencies to build "human capacity and infrastructure;"
  • policy reforms to address social and economic conditions that produce vulnerability to HIV/AIDS;
  • research into new prevention strategies; and
  • efforts to understand spending in low- and middle-income countries.

Ironically, just as the HIV Global Workshop findings were being published in a journal for political analysis, the HIV Medicine Association of the Infectious Diseases Society of America published a group of 3 papers to address this other important issue.1 Vermund, on behalf of the Infectious Disease Society of America (IDSA) and the HIV Medicine Association, has written a Consensus Statement. A group of scientists led by a Tufts-New England Medical Center group with academic connections in South Africa wrote a second article of how to set the research agenda. A third group from the Macfarlane Burnet Institute in Melbourne wrote the last article on monitoring HIV infection in resource-constrained countries.

In the last article from Australia, the Macfarlane Burnet researchers present several low-cost methods to monitor CD4+ lymphocytes and viral loads. As much money as is needed for treatment of HIV-infected patients in poor countries, very little has been discussed about evaluation of therapies. For example, a test called a Cavidi assay is a simple way to measure viral load. One mL of plasma is needed but can be diluted for testing.

Several bead methods (the Coulter Manual CD4 Count kit and the Dynabead T4-T8 systems) approximate flow cytometry for helper-cell quantitation. Other low-cost options are being studied for CD4+ lymphocyte determination. These systems go by names like the Capcelia CD4/CD8 whole blood assay and the TRAx CD4 Test Kit, both of which work with an EIA format. What the Macfarlane Burnet study doesn’t tell us is what the savings need to be with less expensive methods to make them feasible.

The Tufts group, led by David M. Kent, came up with an agenda that sounds much like that in the developed world: development of guidelines, monitoring for toxicity and treatment failure, and determination of drug failure and viral resistance. Factors that affect adherence are important in poor countries too. Kent lists the classic issues like pill burden, poor doctor/health-care provider relationship, youth and substance abuse—all clearly important for the standard Western patient as well as a poor African. What Kent doesn’t discuss are the factors like the number of miles patients have to walk to get medication, cost of treating comorbid conditions, and STD management and prevention.

The Consensus Statement refers to 87 articles. What emerges are 8 concepts that could be applied to trial designs. Concept 11, in particular, seemed exciting to me. It asks the question of whether the use of ART alters how the community used counseling and testing centers or alters the prevalence of unsafe sex. The consensus advises the development of low-cost methods that the Australian paper discussed. Another concept, No. 10, was imaginative. In this proposed study, clinical signs would be used instead of routine surrogates for quality care. And who said physical diagnosis was dead? It would just be too ironic if truly careful history and physical diagnosis in poor countries could help estimate the degree of HIV-induced immune damage.

Comment by Joseph F. John, Jr., MD

Momentous is how I find the scope and vision of this report. What a great contribution these workers and thinkers have given a world at the edge of an HIV abyss! Humans are notorious for their capacity for denial, and we have denied the extent and threat of the HIV epidemic from its outset. This publication in Foreign Affairs2 should be parlayed as soon as possible into the medical literature. Had it not been for my occasional foray into the literature of international relations, I would have missed this report, also.

Well, here it is, and the question becomes, "What next?" What next indeed since the report misses giving the world a springboard to the massive infusion of money that is need to give us a chance to avoid the worst-case scenario. The enlightened initiative by the Bush administration is a start, but I find myself asking just how to create what is a new flood of dollars to fund global HIV—its prevention (that is best), its care (that is human), and its research (that is necessary) over the next 4 years.

If we do not follow the recommendations of the working group, in 4 years the world may look quite different. Those countries like Uganda in sub-Saharan Africa may start to benefit from their success not only in material but also in political fashion. Larger countries like China may find—like Africa found in the 1980s—that its workforce is decimated by HIV and that the cost of treating victims and the cost of lost work dismantles the Beijing economic miracle. The types of threats emerging to developed countries that a further dismemberment of the Third World by HIV would produce are too horrible to envision. Concepts like world order and global nationhood would certainly suffer.

What are we missing? Bridging the gap was stage one. That bridge, though shaky, has grown over the last decade, north south and east west. Closing the gap is next, making access to HIV prevention a reality for billions of people who lack it and budgeting enough new resources to make a difference felt.

In my opinion, the next phase would be the creation of financing mechanisms to pay for the scope of changes that the Global HIV Prevention Working Group has presented here. The financing cannot simply come out of existing federal budgets. New instruments and concepts need to be presented. For example, perhaps the model of state financing in the United States for Medicaid, AIDS Drugs Utilization Programs (ADUP), and creation of new medical programs through penny taxes on items like soda pop could be initiated. Maybe some of a national lottery proceeds could contribute sizably to the need. Maybe some of you readers have better ideas.

Our leaders need to understand the real and present danger of global HIV/AIDS and the impossibility of providing adequate support with current funding levels. The alternatives to missing the current opportunity for meaningful funding remain abhorrent to the medical community.

We in the IDSA should be proud of our society for addressing the issue of global HIV/AIDS and how to really help poor countries. Thanks to Vermund for closing the gap on what has become the global misery of HIV disease. There is a comprehensive report of the Consensus Statement written by Chris Collins available at http://www.idsociety.org/ME/HIVConferenceReportFinal.pdf.

Dr. John is Chief, Medical Subspecialty Services, Ralph H. Johnson Veterans Administration Medical Center; Professor of Medicine, Medical University of South Carolina, Charleston, SC.

References

1. Vermund SH (editor). HIV/AIDS Therapeutic Research Agenda for Resource-Limited Countries. Supplement to Clin Infect Dis. July 1, 2003.

2. Access to HIV Prevention. Closing the Gap Global HIV Prevention Working Group Supplement to Foreign Affairs, May 2003.