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How Do We Scale-Up Access to ARVs?
Treatment Now

AIDS is the world's most disastrous pandemic. It is a medical, social, economic and political crisis. Effective treatments exist, but a mere 4 percent of those in need have access to them. Of the 42 million people worldwide living with HIV/AIDS, more than 95 percent of them live in the developing world. To reach the more than 6 million people who clinically require treatment now, governments and the entire international community must commit the necessary financial, technical and political resources needed to scale-up treatment. This can be done by taking measures to significantly increase funding for AIDS programs, ensure generic competition in order to continue bringing down the prices of AIDS drugs, and supporting and implementing operational research to adapt care models to resource-limited settings, and move toward largely nurse-managed care. All of these measures must ensure a community-based approach to care and treatment that involves people living with HIV/AIDS at all levels. As a medical humanitarian organization, Doctors Without Borders/Médecins Sans Frontières (MSF) believes that governments, policy-makers, aid agencies and others can no longer ask whether they can begin providing wide-scale treatment for the millions of people who desperately need it. They must answer how.

Overview of MSF's HIV/AIDS Programs
MSF's experience with the HIV/AIDS crisis began in the late 1980s. Initially, MSF devoted its resources toward preventing the spread of the disease. By 1997, MSF was running approximately 30 HIV/AIDS projects, still aimed primarily at prevention. At that time, in wealthy countries, new antiretroviral (ARV) therapy, or highly active antiretroviral therapy (HAART), proved extremely effective in extending and improving the lives of people with AIDS. The absence of treatment programs in developing countries stood in stark contrast, and today, in sub-Saharan Africa, people with AIDS still often die within months of their HIV diagnoses. As HIV continues to spread rapidly in many areas, MSF continues to support and conduct prevention activities, but is now augmenting those activities with model treatment programs in Africa, Asia, Latin America and Eastern Europe.

Introducing Antiretroviral Treatment in Resource-Poor Settings
In 2001, MSF launched several programs in Africa, Asia, Latin America and Eastern Europe that provide ARV treatment as part of a comprehensive continuum of care to extend and improve the quality of life of our patients. These programs not only demonstrate the feasibility of implementing ARV therapy in poor countries, but they have also yielded important lessons about how to adapt such programs in severely impoverished communities.

As of June 2003, MSF was providing antiretroviral (ARV) therapy for approximately 5,000 patients in 23 programs in 14 countries: Burkina Faso, Cambodia, Cameroon, Guatemala, Honduras, Indonesia, Kenya, Malawi, Mozambique, Myanmar, South Africa, Thailand, Uganda and the Ukraine. By the end of 2003, MSF expects to be treating around 10,000 patients with ARVs and, in 2004, anticipates running a total of nearly 50 ARV treatment programs in 30 countries. Additional countries will include Angola, Benin, Burundi, Chad, China, Democratic Republic of Congo, El Salvador, Ethiopia, Guinea, Laos, Nigeria, Peru, Rwanda, Sierra Leone, Sudan, Zambia and Zimbabwe.

At the XIV International AIDS Conference in Barcelona in July 2002, MSF presented preliminary clinical results from pilot ARV treatment programs in seven countries: Cameroon, Kenya, Malawi, South Africa, Cambodia, Thailand and Guatemala. These data demonstrate beyond a shadow of a doubt that ARV treatment is feasible and effective in resource-limited settings. At six months, the average increase in CD4 cell counts for patients in MSF programs was 104 cells per mm3, the average weight gain was 3 kilograms and, where tested, 82 percent of patients had undetectable viral loads. Adherence rates were also impressive, with 95 percent of patients taking their medicines properly at six months.

In addition to the clinical benefits of providing ARV treatment, the provision of treatment has also significantly strengthened prevention efforts by, for example, providing an incentive for people to come forward for voluntary counseling and testing (VCT), promoting openness about HIV and reducing its stigma. Since introducing a comprehensive package of AIDS care that includes ARV treatment in the MSF project in Khayelitsha township in South Africa, VCT increased from 1,000 in 1998 to over 12,000 in 2002.

Promises Do Not Treat HIV/AIDS
Recent commitments by the U.S. government to increase financial resources for treatment in Africa are welcome, but they are long overdue. They must also be viewed critically, given the tendency of the U.S. government to renege on promises made to the international community related to access to treatment. Much has been made of President George W. Bush's $15 billion Emergency Plan for AIDS Relief announced during the State of the Union address in January, but it is imperative that serious questions are asked during and after the President's trip to Africa, since he is putting AIDS and trade at the top of his agenda.

Will the promised funding levels actually materialize from Congress with the urgency required? Are there guarantees for the sustainability of this funding over the long-term, as ARV therapy is life-long? What proportion of funds will be spent on a bilateral program that has yet to be created, versus existing mechanisms like the Global Fund to Fight AIDS, Tuberculosis and Malaria -- which already delivers funding for life-saving treatment programs and is facing severe budget shortfalls?

How efficiently will the money be spent when it comes to treatment? Specifically, will funds be made available for the purchase of the most inexpensive quality drugs, including generics, in order to treat the largest number of people possible, or will the bilateral initiative become a "windfall" for the pharmaceutical industry?

Is the Bush administration "giving" with one hand and "taking" with the other through multilateral, regional and bilateral trade negotiations that threaten to restrict access to medicines? Will that happen with the free trade agreement the U.S. hopes to negotiate with the Southern African Customs Union, which would provide more stringent patent protection for life-saving pharmaceuticals than is required in the World Trade Organization's Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS)?

People with HIV/AIDS in the developing world should not have to continue to ask these questions. For them, it is a matter of life and death. They don't need more promises of goodwill from the U.S. and other governments. They need treatment today. And that means serious, uncompromising political action must happen now.

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