Médecins Sans Frontières (MSF) started providing antiretroviral therapy (ART) in 2000, and is currently supporting care and treatment for more than 160,000 people in more than 27 countries. Ten years ago, the biggest challenge was to demonstrate that ART was feasible in low-resource settings. Today, the challenge for governments is to continue to provide support for the millions of people receiving ART, while increasing access to for those who have yet to receive treatment.

Today, some three million people are receiving ART. In settings with high ART coverage, substantial reductions in illness and death have been documented as access to treatment has increased. However, the crisis has not gone away. The harsh reality is that too many people in developing countries continue to die needlessly because they still do not have access to treatment: according to latest estimates some nine million people in need worldwide are still not receiving ART.

Despite this enduring need, there are now worrying signs that the donor commitment needed to sustain and increase the current momentum in the fight against HIV/AIDS is waning. This report summarizes in-depth field analyses of trends in ART access and donor funding in eight sub-Saharan African countries where MSF has been providing HIV/AIDS care and treatment for several years. The report findings are the result of interviews with people living with HIV / AIDS, care providers, government representatives, donors, UN agencies and through a review of policy documents.

Positive impact of HIV/AIDS treatment interventions during the past decade

Saving lives: The provision of ART on a large scale has prevented millions of deaths and allowed millions of people with HIV/AIDS to maintain or resume an active life. Experience from Thyolo, Malawi, where in partnership with the health authorities MSF has provided universal access to ART since 2007, showed a significant downward trend in mortality coinciding with the scaling up of HIV/AIDS care and treatment, which suggests that ART is having an impact on mortality at the population level.

Preventing tuberculosis: Tuberculosis (TB) is one of the leading causes of illness and death among AIDS patients. In Khayelitsha, South Africa, where approximately 70% of TB patients are HIV positive and approximately 50% of HIV patients have TB when they are initiated on ART, the annual absolute number of TB cases has stabilized; this can partly be explained by the large-scale ART coverage in the district.

Reducing transmission: Increasing ART coverage has also contributed to reduced HIV transmission in the community and models of expanded HIV testing and treatment, both at population level or among specific groups such as pregnant women or high risk groups, are promising.

Reducing the burden on health facilities: Widespread availability of ART has also reduced the burden on health facilities, in particular the demand for inpatient and palliative care. In Busia, Kenya, the proportion of people hospitalised has decreased with the availability of ART: the proportion of bedridden patients declined from 10% in 2004 to less than 2% in 2009 as a result of increased ART coverage.

Improving uptake of other health services: The offer of HIV/AIDS care also often leads to improved uptake of other services. For example, prevention of mother to child transmission (PMTCT) programmes can lead to increased numbers of women receiving maternal care. In MSF’s project in Thyolo, Malawi, thanks to PMTCT initiatives and simultaneous support to reproductive health care as a whole, the proportion of women (regardless of HIV status) delivering in health centres nearly doubled from 22% in 2006 to 41% in 2008.

Strengthening health services: ART programmes often result in broad improvements in health services. In Thyolo, Malawi, the monitoring and evaluation tools that were initially developed for HIV/AIDS were adapted and used for laboratory activities, nutrition and hospital wards. Drug supply management tools that were created for AIDS drugs were then applied for general drug supply management, thus benefitting the entire health service.

Reduced loss of healthcare workers: The introduction of ART has also averted many deaths among health workers. In Zambia, deaths account for up to 40% of all nurse attrition from the public sector; in Lesotho, Malawi and Mozambique, death is the main reason for attrition among health workers. Between 2006−2009, in a staff clinic in Thyolo district, Malawi, 67 out of 747 health workers were initiated on ART and stayed healthy enough to continue working.

Treatment gap

ART roll-out so far has been impressive, but insufficient. Access to treatment has steadily increased in most of the countries studied, thanks to the combined efforts of numerous actors. Nonetheless, there is still a long way to go; none of these countries has yet reached the national “universal access” target of 80% of people in need of ART on treatment, leaving a treatment gap of some two million people.

In spite of the ongoing crisis, donors speak less and less about targets for treatment. Yet no longer talking about quantified targets when fighting an epidemic makes no sense; evaluating progress in a quantified manner is crucial. Even UNAIDS no longer has a global mobilising target beyond 2010. Universal Access was previously commonly understood as coverage of at least 80% of the needs. Today, increasingly Universal Access is interpreted as “any objective of coverage set by the country.” The present reality is that, in spite of the undeniable epidemic character of HIV/AIDS, many countries’ ambitious objectives have been watered down, discouraged by the bleak funding perspective.

Access is about sufficient available treatment slots and ART sites distributed across the country. Today already, poorer patients cannot access the ARV lifeline, and rural areas in particular are underserved. MSF teams frequently see patients whose only option for treatment is to travel long distances to clinics where ART is available. In Zimbabwe, up to 20% of the patients at MSF clinics are from other districts: they come here seeking to start ARV, because they cannot get in time the treatment they need at health facilities near their homes. We see similar ‘treatment migrants’ in MSF-supported clinics in Zimbabwe, DRC, Mozambique, Kenya, Uganda and also in Guinea-Conakry and Central African Republic. In Kinshasa, DRC, patients arrive late, often in critically weak condition, not because they did not seek care, but because the health facilities they consulted did not have ART available or patients could not afford the 15 USD for a CD4 test that would allow them to start ART.

Limiting scale-up and geographical coverage of sites providing ART will only worsen these inequalities and provoke a renewed rise in avoidable deaths. Any retreat from the current efforts of ART scale-up will have important negative consequences for patients and front line workers:

• Patients will have to wait longer to start ART and are at risk of dying before they can have access to life-saving medication. Patients left untreated risk deteriorating and succumbing to opportunistic infections (OI) such as TB. More patients will be lost to follow up, even before they can start ART.
• Patients starting with lower CD4-counts require more frequent, more intensive and more costly care; at the same time they have a lower chance of survival and take longer to recuperate.
• The patient load at health facilities will increase and health workers will be discouraged by the worsening outcomes among the patients to whom they provide care.
• Patients might start sharing their pills, effectively lowering their dosage and increasing the risks of virus transmission and resistance.
• Tensions will rise between patients already on treatment and those not yet on treatment.
• Tuberculosis rates will increase and represent an additional burden on already busy clinics.
• Mortality rates among adults in the prime of their lives and the number of orphans will rise again in the community.
• Insufficient ARV availability will require a slowing down of testing and counselling activities.

Acute funding crisis as donors retreat from epicentre of the HIV-epidemic

A brief survey of donors’ plans for the next years illustrates the challenges:

One key donor, PEPFAR, has flatlined its funding for 2009-2014 and as of 2008-9, further decreased its annual budget allocations for the coming years by extending the period to be covered with the same amount of money. The funding for purchase of ARVs will also be reduced in the next few years. All this translates into a reduction in the number of people starting on ART, as we have seen in South Africa and Uganda.

The World Bank currently prioritises investment in health system strengthening and capacity building in planning and management over HIV dedicated funding. However, without fund for ARV drugs and related costs, the impact of such capacity to support HIV/AIDS care will remain very limited.

UNITAID is phasing out its funding. By 2012, the drug and other medical commodity procurement organised by the Clinton Foundation for HIV/AIDS and funded by UNITAID for second line ARVs and paediatric commodities should end in Zimbabwe, Mozambique, DRC and Malawi.

The Global Fund is currently facing a serious funding shortfall. In October 2010, a donor replenishment conference is planned with the aim of mobilizing more resources, but donors have already requested the Global Fund to lower its financial ambitions. All current funding scenarios are inadequately required to implement the new WHO guidelines on earlier treatment and improved drug regimens.

With very few exceptions, other health actors such as the European Commission and European Union Member States do not fund HIV/AIDS treatment directly and hardly ever finance ARV supplies besides through their contribution to the Global Fund. At present, these donors seem unlikely to fill the additional gap created by the current shortfall, yet remain reluctant to increase their support to the Global Fund.

These trends fall within a more general move away from funding emergency interventions to providing indirect support. Since 2005 most donors have signed the Paris declaration, a framework to ‘improve effectiveness of their development aid’. In line with this discourse of alignment and building country systems, donors now prefer to use AIDS treatment funding to finance capacity-building, technical assistance, consultancies, and one-off investments rather than service-delivery activities.

Health without addressing HIV/AIDS?

While health systems in developing countries undoubtedly need huge support, the risks of removing specific attention from HIV/AIDS are already becoming clear.

• Several donor countries (and several governments of recipient countries) are asking that money pledged to the Global Fund also be used for more health systems strengthening, interventions for mother and child care etc. without adding any financial resources. As the Global Fund is now perceived as a highly effective funding channel delivering results for Millennium Development Goal (MDG) 6 (HIV/AIDS malaria, and other major diseases), these donor countries are pushing to expand the Global Fund’s mandate to include interventions aiming at MDG 4 (child mortality) and MDG 5 (maternal health) as well. But without a significant increase of funds to the Global Fund, this will inevitably lead to further depletion of funding available for HIV, malaria and TB.

• The US government’s current Global Health Initiative (GHI) highlights health system strengthening and improvement in human resources for health under PEPFAR II. In Zimbabwe, treatment support for at least 3,000 adults is due to be redirected to focus solely on mothers by 2011, to fit with the US’s current emphasis on maternal and child health. President Obama’s Global Health Initiative (GHI) highlights health system strengthening and improvement in human resources for health under PEPFAR II. A focus on pregnant women is used for rationing of care, like in Uganda and Zimbabwe. In Zimbabwe, treatment support for at least 3,000 adults is due to be redirected to focus solely on mothers by 2011, to fit with the US’s current emphasis on maternal and child health.

There are numerous cross-benefits and spin-offs of effective HIV/AIDS interventions for wider health issues. HIV/AIDS specific interventions have brought significant improvements in other health priorities and contributed to health system strengthening as a whole. Ignoring the HIV/AIDS epidemic would only bring about a ‘lose-lose’ situation. Indeed, targeting the MDGs cannot possibly be done without properly tackling HIV/AIDS. In Mozambique, 10% of deaths among children is attributed to HIV (2009) and in Zimbabwe the main cause of maternal mortality is HIV. Maternal mortality is significantly higher among HIV positive women. It has been estimated that without HIV/AIDS, maternal mortality in 2008 would be 20% lower, while another study concluded that HIV is one of the main reasons for countries not progressing towards the MDGs.

Impact of donor retreat

As ARV treatment is lifesaving but also lifelong, the number of patients on treatment will increase cumulatively each year. If the intentions to quell the epidemic are serious, initiation on ART needs to keep the same incremental pace as that seen over the past years. As most countries in sub-Saharan Africa do not have the domestic resources to shoulder the financial burden of HIV/AIDS treatment alone, a steady increase of funding is needed over the next decade.

A recent World Bank report estimated the impact of not increasing funding for HIV/AIDS. It stated that “New infections would continue to increase, and deaths from HIV/AIDS would grow from the 2005 level of 1,9 million deaths and 14 million newly infected persons (an increase of 50 percent from 2006). The report concluded that the cost of inaction will be higher than that of action. Also others have indicated the medium term benefit of not postponing scale up of treatment.

In countries where MSF works, signs of donor retreat are already beginning to impact negatively on ART scale-up efforts.

Hasty exits lead to rationed ARV initiation. When donors “move out” of funding for HIV/AIDS interventions, they aim to negotiate the hand –over of the financial responsibility to another actor. But the reality is that this transition is rarely planned for in advance and cannot always be absorbed.

The grants of the Global Fund might come under increased strain, as happened recently in the DRC: taking over treatment costs from other donors into an already limited grant resulted in a five-fold reduction in the actual monthly funded treatment slots.

The concept of “doing more with less” is interpreted

Latest WHO recommendations are being ignored because of budget concerns. The new WHO guidelines, launched at the end of 2009, recommend a number of important improvements to ART care, most significantly the earlier initiation of ART (at a CD4 count of <350 cells/μl rather than <200 cells/μl) and the provision of improved drugs with less associated toxicity. The WHO recommendations are met with relief by all clinical and public health experts.

As a consequence of funding shortfalls, compromises are being made. For instance, Mozambique and Uganda decided to start initiation at CD4 counts of <250/μl instead of the recommended <350/μl, with Uganda choosing the earlier initiation only for certain groups. Other countries, such as Malawi and Kenya, await financial support to implement the recommendations that have already been technically approved.

Increased fragility of funding and supplies

MSF teams have noted that uncertainty around the levels and continuity of funding for HIV/AIDS treatment supplies can have rapid negative consequences. In Malawi, an administrative delay in signing the contract with the Global Fund delayed disbursement and consequently delayed crucial drug orders, leading to serious ARV supply shortages at health facility level. A similar situation occurred in Mozambique in the beginning of 2010, where a delay in disbursement of Global Fund funds resulted in ARV supply delays.

Disruptions of supply have been more frequently noted in 2009 and 2010 in almost all countries studied. Whereas previously, MSF-supported health facilities would receive the majority of the ARV needs through government channels, financed by the Global Fund, UNITAID/CHAI and PEPFAR, with a relatively limited need for MSF to complement ARV supply, in 2009 and 2010, MSF had to increase its buffer stocks significantly and provide more regular emergency supplies to MSF-supported clinics in Mozambique, Malawi, Uganda, and DRC.

Other implementers often do not have the resources or capacity to “fill gaps” left by the national programme. In 2009 and 2010, MSF was increasingly confronted with requests
from other actors to help them out with emergency supplies, including from the Ministry of Health, international and local NGOs, and patients groups outside the MSF project area.

Ultimately, the consequences of unreliable ARV supplies are borne by patients and health workers, as shown by recent experience in Malawi, Mozambique, Zimbabwe, DRC, Uganda, Kenya and South Africa. Health workers may deal with the delays or shortage by changing patients onto other pills (for instance, using different dosage or different drugs from alternative regimens with more side effects, or splitting adult pills for children), or giving patients pills for a shorter period of time, increasing the workload at already busy health facilities. Patients may seek treatment elsewhere or may be required to wait until their CD4 counts drop to a greater degree before being initiated on treatment. Patients might start pill-sharing or taking sub-optimal doses, which may lead to the development of drug resistance. Knowing that ART has to be taken for life, both patients and health workers may lose the confidence to start.

The HIV crisis if far from over

Moreover, evidence has shown that effective HIV/AIDS interventions have numerous cross-benefits and spin-offs on the brader helth sector. Achieving the MDGs cannot be tackled without addressing HIV/AIDS. And yet a lack of sustained donor commitment is jeopardising worldwide efforts to fight this deadly disease, and there is little or no discussion on how to resolve the funding crisis. To prevent needless illness and excessive loss of life, renewed and expanded donor commitment is necessary; sustained international funding is direly needed to help bridge the treatment gap in sub.Saharan Africa.

* Médecins Sans Frontières (MSF) is an international humanitarian organisation. This article is based on the most recent analysis of the widening gap for HIV/AIDS treatment in sub-Saharan Africa. Full Document including all the references: Médecins Sans Frontières 2010, No time to quit: HIV/AIDS treatment gap widening in Africa. Accessible on:
http://www.msf.org/source/countries/africa/southafrica/2010/no_time_to_quit/HIV_Report_No_Time_To_Quit.pdf