Experience and vision from an organization working hands on in limited resource countries
How far are we of a future without AIDS?
Von Johnny Lujan / Médecins Sans Frontières Schweiz
MSF has been one of the leading non governmental organizations engaged in the fight against HIV/AIDS in limited resource settings (LRS). Many people will remember the pioneers from the organization that in the late 90s, looking powerless at their patients dying of AIDS, had decided to smuggle antiretrovirals into places where the needs were devastating; a few persons would have believed that this initiative would lead the MSF to start such commitment along the last 15 years
MSF has implemented different strategies to increase access to life saving antiretroviral therapy (ART). Testing, adaptation and innovation of these strategies have been among the founding principles to achieve and promote access to ART.
Today, in low and middle income countries, very much progress has been achieved and many deaths have been prevented due to ART, the number of people receiving ART rose from less than 200’.000 persons in 2011 to around 9.6 million today. But in despite of this progress, we also have to accept that a lot has to be done yet. Extremely low access to ART is the case in some countries yet (in the Democratic Republic of Congo –DRC- and Central African Republic, extremely low coverage of ART in adults is a clear example of this precariousness). And we cannot do other things in these days than just observe how much evidence has science provided and how scarce the means to implement this evidence are, it is a tragedy that only 2% of HIV infected pregnant women got access to PMTCT in DRC in 2011.
Investing Framework for HIV
In regards of the UNAIDS sponsored strategy (Schwartländer et al. 2011), the following program activities can explain how MSF has invested its main efforts against HIV/AIDS in the last years:
MSF main aim in HIV/AIDS action is keeping patients alive. Meeting patients’ needs being the principal priority for MSF, the organization is contributing currently to follow around 40’000 patients under ART, out of which, nearly 7% are children. This achievement has been possible through our work on strategies aiming to expand ART such as decentralization of care, task shifting and simplification.
Prevention of mother to child transmission of HIV (PMTCT); MSF is well aware of the importance of this activity and is investing important efforts in backing up for some time already, the implementation of the 2013 WHO recommendations (PMTCT B+: All pregnant women being HIV infected should start ART regardless their CD4 counts); some of our projects (Swaziland, Myanmar and Mozambique) are highly involved in this activity.
Acknowledging that community participation is a main social enabler, MSF works with lay counselors and expert patients to provide literacy and counseling support for our patients. Involving communities to expand testing and linking those tested as HIV positive to the health structures are currently activities highly prioritized by MSF. Community based ART delivery is in the loop as one of the main points to be developed in the following years.
In South East Asia (Myanmar), we have as objective for the following years to work with most at risk populations; testing Men who have Sex with Men, sex workers and drug users and linking them to care for ART initiation regardless of CD4 counts is going to be one of the main goals of these actions.
Finally, in highly endemic countries, MSF promotes early initiation of ART for all HIV infected patients. A test and treat approach for all HIV infected patients will be implemented in Swaziland in the following years looking for getting a better knowledge of how to implement such enormous strategy which main objective is to curb the epidemic.
A Future without Aids: Happening soon?
MSF believes that a future without AIDS is possible but based on our field experience we remain a bit skeptical about it happening soon. There are enormous challenges yet to be overcome.
The progress and achievements made so far are weak; sustainability of political and programmatic commitment as well as international – and national-funding are among the main difficulties to be solved. There are still countries with extremely low access to basic care and ART, and where not much has evolved in the last time; there, the implementation of the innovative 2013 WHO recommendations remains uncertain.
Even doing big efforts to beat tuberculosis (TB) and especially multidrug resistant TB, we are not providing solutions to the mortality by other killers in HIV infected patients; cryptococcal meningitis recognized by WHO as a main cause of mortality in sub Saharan Africa, even far ahead of TB, is not being faced to as it should. And patients without access to HIV care and ART are still dying of undiagnosed opportunistic infections. Comorbidities such as Hepatitis B and C remain not tackled.
Moreover, due to the characteristics of the HIV infected population, other diseases are also threatening them; this is the case of chronic diseases that will affect much more HIV people than the not HIV infected population; and as patients on ART are aging and reaching comparative quality of life as the not HIV infected, cancers are starting to be considered also as an important menace.
Other basic challenges remain unsolved; patients require to achieve undetectability of viral load in order to control HIV; getting patients alive and cutting transmission depends on undetectability of viral load; currently, we do not know how the big cohorts in LRS are doing on this aspect, many could be already failing to ART and thus, in need of alternative antiretrovirals.
Additionally, we realize nowadays that HIV infection is spreading further in most at risk populations such as drug users in Eastern Europe and central Asia; HIV is also scattering to previously not affected populations, such as injecting drugs users and men who have sex with men in some parts of Africa, where widespread homophobia does not allow these men to get access to HIV care and ART.
To conclude, and paraphrasing Dr Piot, the former executive of UNAIDS (Piot/Quinn 2013): even when the most effective HIV interventions are used, most mathematical models suggest that by 2031 there may still be as many as 1 million new infections globally every year. These programs will require universal access, large scale implementation, careful monitoring and evaluation, financial and technical resources, and robust commitment. Only then may we begin to see a substantial effect on the global spread on HIV infection.*Johnny Lujan, MD, Medical Department of MSF Switzerland, Contact: Johnny.LUJAN@geneva.msf.org
- Bernhard Schwartländer et al: Towards an improved investment approach for an effective response to HIV/AIDS. Lancet 2011: 377: 2031 – 2041
- Peter Piot and Thomas C Quinn. Response to the AIDS Pandemic – A Global Health Model. N Engl J Med 2013; 368: 2210 - 8