Mauricio Mercado Garzas, of Mexico City, is a member of the National Front of People Affected by HIV/AIDS, a citizens' action group that has worked to expand access to antiretrovi-ral treatment in Mexico. Diagnosed as HIV-positive in 2000, Mercado has been on treatment for four years. Photo ©Keith Dannemiller
Casting the AIDS Lifeline
by Donna Eberwine
They call it the "Lazarus effect." Like the biblical figure Jesus raised from the dead, an ailing and emaciated AIDS patient receives antiretroviral therapy and within months undergoes a dramatic recovery.
Andrés Vargas, a general practitioner turned AIDS specialist in Cochabamba, Bolivia, has seen it happen.
"I have a young male patient, 23 years old, a mechanic who works in his family's machinery repair business," says Vargas. "In July 2002, he was diagnosed with non-Hodgkin's lymphoma. His weight had fallen to 75 pounds, he had thrush, fever, diarrhea, and herpes." Doctors gave him chemotherapy for the lymphoma, but by September he had developed tuberculosis, which was also treated. In late October, his family raised enough money to buy him antiretrovirals. "Eleven months later, his weight was up to 140, he had no symptoms of infection, and he was back working and living a normal life. Then, because of a lack of money and donations, he had to go off the treatment, and by January of 2003, he was back in the clinic with herpes zoster [shingles] on his right arm. But thanks to a donation from Brazil in February, he was able to go back on treatment. Now, within two months of restarting treatment, he is asymptomatic and back at work again."
Less than a decade ago, such an outcome was within reach of only a privileged few in Latin America and the Caribbean. In the mid-1990s, more than 30,000 AIDS sufferers were dying each year, more than 500 people were becoming newly infected every day, and only a minority had access even to single-drug treatment.
There are both practical and moral reasons to link treatment with prevention. "We know from experience that treatment reinforces prevention," says Paulo Lyra, a communications specialist in PAHO's HIV/AIDS program.... [Read more]Today Latin America and the Caribbean lead the developing world in providing anti-retroviral treatment, with an estimated 210,000 HIV/AIDS patients—55 percent of those believed to be in need—on treatment throughout the region. In Africa, by comparison, only 100,000 of some 4.4 million people who need them are receiving these drugs. Indeed, Latin Americans and Caribbeans account for more than half the total number of people receiving antiretroviral treatment throughout the developing world.
That's small comfort for the men, women and children in the region who still need but do not have access to treatment. Yet public health advocates say the achievements reflect a growing commitment to providing universal access to antiretroviral therapy.
"Today, every country in our region has HIV/AIDS patients on antiretroviral treatment," says Carol Vlassoff, head of the HIV/AIDS program at the Pan American Health Organization (PAHO). "Some of them are just beginning the process and there are a lot of delays and obstacles. But there's a new consensus that everyone in our region who needs AIDS therapy should have access."
To support this process, PAHO is spearheading a regional initiative over the next year and a half to increase the number of people receiving AIDS therapy in Latin America and the Caribbean by 174,000—the number currently believed to need treatment but who still lack access. The region's heads of state endorsed this ambitious target at the Summit of the Americas in Monterrey, Mexico, in January, when they called for treating 600,000 people throughout the Western Hemisphere. The effort will also support the so-called "3 by 5" initiative, launched by the World Health Organization (WHO) in late 2003, with the goal of providing antiretroviral treatment to 3 million people in the developing world—half of those estimated to need it—by the end of 2005.
In 1996, the life-extending promise ofcombination antiretroviral therapy was brought to the world's attention, giving new hope to millions of people living with HIV/AIDS. Presenters at the 11th International AIDS Conference in Vancouver, Canada, demonstrated that highly active antiretroviral therapy (HAART), which combines three or four antiviral drugs, produced dramatically better results than single-drug treatments. AIDS patients on HAART showed drastically reduced viral loads, significantly boosted immune systems, and far fewer opportunistic infections than untreated patients or those on single-drug treatment such as zidovudine (AZT). Though not the long-hoped-for "cure," HAART meant that AIDS could be transformed from a virtual death sentence into a chronic but controllable disease.
Patricia Pérez, of Buenos Aires, Argentina, was 26 years old when her HIV test came back positive. "Back then, the news was a death sentence," she recalls 16 years later... [Read more]
Since HAART became available, death rates from AIDS have declined 90 percent in the United States and Europe, and middle-income countries including Argentina, the Bahamas and Brazil have seen as much as a 50 percent drop in death rates from AIDS in only a few years of treatment. Hospitalizations have declined dramatically as well. But in the world's poorer countries—particularly in Africa, but also in many countries in Asia and the Americas—AIDS deaths have continued to climb along with new infections.
The cost of treatment has been the most obvious impediment. When HAART became available in the 1990s, the cost of a year of treatment for one patient averaged $10,000–$15,000—expensive even by North American standards, but prohibitive in most of the developing world.
With treatment perceived as largely out of reach, Latin America and the Caribbean's efforts to fight the epidemic at first "focused almost exclusively on prevention," says Rafael Mazin, PAHO regional advisor on HIV/AIDS. "This may have been an appropriate public health response in the epidemic's early stages," he says.
"There was also the argument that patients in developing countries wouldn't take the medication properly, and resistance to the drugs would develop. It was considered wiser to invest what limited resources there were in prevention more than treatment," Mazin says.
A notable exception to this rule was Brazil. Facing a rapidly spreading epidemic in the early 1990s, Brazilian health authorities responded to the crisis with a comprehensive strategy that incorporated both prevention and treatment, along with substantial funding and an emphasis on human rights and the participation of people living with HIV/AIDS. An integral part of the strategy was universal access to free antiretroviral treatment.
"Our goal was to improve the quality of life for people living with HIV and AIDS," says Ricardo Pio Marins, deputy director of Brazil's National Program for Sexually Transmitted Diseases and AIDS. "This required putting the subject firmly on the political agenda—placing the highest political and institutional priorities on controlling the epidemic—and using a management model based on decentralization and involving a wide range of governmental and nongovernmental sectors, including those groups most affected by the epidemic, especially people living with HIV and AIDS."
Activists in Lima, Peru, call for expanded access to antiretroviral treatment for people living with HIV/AIDS, during a demonstration on World AIDS Day 2003. Photo ©Rosa Fernández/PAHO Peru
To tackle the problem of drug costs, Brazil began producing generic versions of antiretrovirals in 1993. In talks with brand-name drug makers, it cited World Trade Organization rules that allow countries in certain cases, such as national emergencies, to use compulsory licenses, which permit them to manufacture or import generic drugs while paying patent holders a reasonable royalty. Though Brazil never resorted to issuing compulsory licenses, its stance gave it leverage to negotiate lower prices with brand-name manufacturers. Today the country spends an average of $1,591 per patient per year on antiretroviral treatment, which it both imports and buys from six domestic manufacturers. Brazil also donates domestically manufactured AIDS drugs to Africa and other Latin American countries including Bolivia, Colombia, the Dominican Republic, El Salvador and Paraguay.
Power in numbersBrazil is one of the few countries in the region with the technical and manufacturing base necessary to produce its own drugs. But other countries have followed its lead in negotiating with drug makers to lower antiretroviral prices.
Brazil's approach to its HIV/AIDS epidemic has emerged as a model for developing countries. Brazil's own health officials credit much of their success to the early adoption of a policy of universal access to antiretroviral drugs... [Read more]
With support from PAHO/WHO and the Joint United Nation Program on HIV/AIDS (UNAIDS), health authorities from 15 Caribbean countries in 2002 negotiated a deal with four pharmaceutical manufacturers that lowered the price of brand-name triple-therapy treatment to as little as $1,100 per patient per year. In early 2003, Central America completed similar negotiations with five pharmaceutical companies that reduced the prices of a year of therapy to between $1,035 and $1,454. Parallel talks with generics makers resulted in prices ranging from $600 to $1,200.
Last June, 10 other Latin American countries, including a number of Andean countries, reached agreement with generics manufacturers to purchase antiretrovirals at reductions of 30–92 percent on individual drugs. This produced prices as low as $400 per year per patient.
Still, the estimated cost per year of treating every HIV/AIDS patient who needs it can be staggering. A number of countries, including Argentina, Brazil, Chile, Costa Rica and Mexico, have been absorbing these costs through their national health budgets and World Bank loans. But smaller and lower-income countries have had to seek other external sources of funding.
One of the most important of these is the $4.7 billion Global Fund for AIDS, Tuberculosis and Malaria, launched in 2002 to channel public and private donations to combat these three diseases. During its first two years, the fund approved more than $240 million in grants to Latin America and the Caribbean, including financing for treatment for more than 50,000 HIV/AIDS patients. The United States' $15 billion President's Emergency Plan for AIDS Relief, known as PEPFAR, focuses primarily on Africa but has also financed AIDS treatment in Haiti and Guyana and pledged $1 billion in general funds to the Global Fund for AIDS, Tuberculosis and Malaria.
Paz Serrano Escamilla, of Hidalgo, Mexico, is a member of the NationalFront of People Affected by HIV/AIDS. Her group was instrumental in extending access to antiretroviral treatment to people not covered by Mexico's social security system. Photo ©Keith Dannemiller
Despite these positive developments, activists complain that the process of expanding treatment has moved far too slowly. Among the most vocal critics is Richard Stern, a psychologist and director of the Agua Buena Human Rights Association in San José, Costa Rica. A U.S. citizen by birth, Stern has traveled widely throughout the region working with AIDS action groups on treatment issues. Following the successful conclusion of drug price negotiations by South American countries last September, Stern complained in an e-mail message to members of the negotiating team: "It is very possible that in some countries where treatment access was already available, that the health care systems are now buying at lower prices than previously, which is good. But as for those whose lives are in jeopardy because they lack treatment access, I can see no difference as a result of these negotiations." Stern has also posted numerous articles on his organization's website documenting the months- and sometimes years-long lag time between the approval of Global Fund proposals and countries' actually procuring and distributing antiretroviral drugs.
Allan Hruska, director of NicaSalud, the principal recipient for Nicaragua's most recent Global Fund grant, agrees with Stern that delays have been a major problem. Following approval of the $4 million grant in January 2003, NicaSalud had to go through 10 separate procedures to actually procure the drugs. After completing the process last March, Hruska described in a message to Stern and others what it had entailed: "We have all of the drug purchases lined up, having: (1) developed the technical specifications of each, (2) convened the procurement committee that includes the Ministry of Health, (3) received a ‘no objection' from the Ministry of Health for their purchase, (4) tendered the procurement, (5) awarded the contracts in committee, (6) reviewed the patent and national registration status of all medications, (7) noti-fied the suppliers of our intent to purchase, (8) negotiated with the Ministry of Health procedures for receiving, storing, and dispersing the medications, (9) signed an agreement with the Ministry of Health to ensure number 8, and (10) received approval from the Global Fund for the purchases."
By all accounts, the most powerful driving force behind expanding access to antiretroviral treatment in Latin America and the Caribbean has been the activism of people living with HIV/AIDS... [Read more]
In an interview, Hruska said he understands that such burdensome procedures may be necessary, but he added: "We've had to learn as we go. We're not a technical agency. It would have been helpful to get more guidance on how to make our way through the process."
PAHO's Carol Vlassoff observes that, following the success of drug price negotiations, "price may no longer be the obstacle." She lists a host of technical, bureaucratic and medical hurdles that need to be overcome, adding that these are high-priority areas for PAHO's "3 by 5" initiative. Among the most pressing needs are: testing equipment to measure patients' viral loads before prescribing treatment; improved laboratory services to follow patients' progress and monitor the development of drug resistance; training for health personnel in HIV testing, counseling, and referral, as well as in prescribing and monitoring drug treatments; and general strengthening of health services delivery.
Vlassoff and others involved in PAHO's "3 by 5" effort acknowledge that universal access to antiretrovirals is an ambitious and difficult-to-reach goal. Haiti alone has an estimated 50,000 HIV-positive people who currently need antiretroviral treatment, but only 2,000 patients are receiving it.
"But this is a goal we have to strive for," says Vlassoff. "We have countries that are already doing it and others that are very close. And now they're sharing important lessons learned with other countries. Of all the developing regions, the Americas have real potential to achieve universal access. It is a challenge, but it needs to be done."
Donna Eberwine is editor of Perspectives in Health.