The Ten Consequences of AIDS Treatment
Delayed, Deferred, or Denied
July 2010www.msfaccess.org

The MSF Access Campaign editorial team wishes to acknowledge
Sheila Shettle’s substantial contributions in writing and finalising
this document.
Cover Photo : Brendan Bannon
Back Cover Photo : Brendan Bannon
Layout : 11mm.net

The Ten Consequences of AIDS Treatment Delayed, Deferred, or Denied“

I don’t think donors really understand what is at stake. If they saw the problem from HIV-positive
people’s perspective, maybe then they would think of a way to sustain HIV/AIDS funding, and to keep
giving additional resources for pressing health care needs. When donors withdraw funding andcommitment for treatment, no matter how slowly, in the end, life for a lot of people in Africa will beeither miserable or nonexistent. – Jimmi Gideyi, PLWHA, Kenya”

Over the last decade, antiretroviral treatment (ART) scale-up tomillions of people living with HIV/AIDS in developing countries has
been possible thanks to a massive mobilisation of resources andpolitical will, the simplification of ART, and the competition among
drug manufacturers that has pushed prices for AIDS medicines
down by more than 99% since 2000. More than four million
people are alive today who without treatment would not be, andepidemiological trends show crucial progress in the battle against
the epidemic. MSF currently provides ART to more than 162,000
people in 25 countries.

But despite evidence of the broad benefits of ART, we arewitnessing alarming backtracking just as efforts should be
ramped up. Donors have started to shift their support away from
HIV/AIDS, and funding is not keeping up with the need. MSF has
seen the negative impact this is already having in some countries:
care is being rationed because of limited treatment slots, slowing
treatment scale-up for those in urgent need, and threatening thelifeline of those fortunate enough to be on treatment. Today, ten
million people are in immediate need of treatment 2 – if nothing isdone, most of these people will die within the next few years.

The World Health Organization (WHO) has recently madeimportant changes to treatment guidelines, and now recommends
that people be provided with treatment earlier, before the diseaseis allowed to progress. This would bring clinical practice indeveloping countries closer to standards long adhered to in
wealthy ones. In addition, new evidence shows that wide-scaleand early treatment may be an effective way to curb transmissionof the virus at population level.1

2010 brings us to a critical crossroads that will determine thesize and pace of the AIDS response for the coming years. Donors
will make the political choice to either fulfil their commitment touniversal access to ART as promised in 2005, or to continue down
the path of disengagement.
This document illustrates ten consequences of the funding
retreat for people living with HIV/AIDS in developing countries,
drawing upon data from MSF field research released at the
XVIII International AIDS Conference (IAC) 2010 in Vienna, andexperience providing ART over the last ten years.

Donors Suffering FromAIDS Fatigue
UNAIDS estimated in 2007 that addressing
the AIDS epidemic in low- and middle-income
countries would require US$25 billion in 2010 i, butdonors have only given roughly half that amountso far.9 With the economic downturn and shifting,rather than increasing, funding to other healthissues such as maternal and child health, donors
have begun to downsize their contributions to HIV/
AIDS:
• The US government’s PEPFAR programme,
initiated in 2003, pays for treatment for more than half the people
receiving ART in developing countries. In May 2009, US President
Obama launched the Global Health Initiative (GHI), which aims
to spend $63 billion over six years (2009-2014) on global healthprogrammes, of which PEPFAR is the largest.10 But PEPFAR’s budget
is being flat-lined – the budget for 2011 marks the third year in a row.
And while PEPFAR support put 2.4 million people on treatment bySeptember 2009, the programme only plans to initiate an additional
1.6 million people on ART from 2009-2014. This means a slowing ofyearly enrolment of new patients by an average of 56% as compared
to 2006-2008.11 PEPFAR has already told some implementers tostop enrolling new patients on ART unless slots become vacant
through deaths or defaulters.12 At the same time, the White House isdecreasing the contribution to the Global Fund to Fight AIDS, TB and
Malaria (GFATM).13• GFATM provides support for one quarter of all people on ART
in developing countries. However, it is facing an unprecedented
funding gap and risks not being able to fund the treatment proposals
submitted by developing countries. GFATM needs at least $20 billion
for the next three years, but donors are reneging on commitments,
and are requesting that GFATM lower its financial ambitions in thelead up to a replenishment conference in October 2010.14
i This estimate is based on old WHO treatment initiation criteria, which underestimates the numberof people in need. The amount of funding needed to address the AIDS epidemic would therefore,
according to latest clinical evidence, be even higher.

• UNITAID, the international finance facility funded primarily by anairline tax, has been providing support for second-line and paediatricantiretrovirals (ARVs) through its partner on HIV/AIDS, the Clinton
Health Access Initiative (CHAI). UNITAID currently pays for ARVs
for three in four children on treatment in developing countries.15 Aswith all UNITAID projects, the idea has been to hand over to otherfunders once supply of quality products and reduced prices have beenachieved. However, given current difficulties to hand over to GFATM
or PEPFAR, funding for second-line and paediatric ARVs, which runsout in 2011 and 2012 16 respectively, may need further extension. This
will limit UNITAID’s capacity to take on new important projects, suchas building viral load testing capacity.
• The World Bank’s Multi-country HIV/AIDS Programme (MAP) has
distributed $1.5 billion in more than 30 countries since it began
in 2000, and has supported ART provision in 26 countries. The
programme has been phased out in three African countries over thelast four years, and will end in a further three by the end of 2011.17• Other donors such as the UK government and other European
Union countries who collectively provide nearly half of the GFATM’scontributions, are either shifting support to maternal and child healthand health systems strengthening, or are cutting back development
and health funding.18

3

Living Proof: The Positive Impact of AIDS Treatment“

People’s lives have been improved, their quality of life has been maintained. There are fewer people
dying of HIV-related complications. There are fewer hospital admissions, fewer people coming to seek
help for treatment of opportunistic infections. It has reduced the workload and the burden of what weare doing. – David Some, Clinical Officer, MSF, Kenya”

Estimated number of AIDS-related deaths with and without ART, globally,
1996 - 2008 (UNAIDS, 2009 AIDS epidemic update)© Kenneth Tong/MSF

Estimate of the annual number of infant infections
averted through the provision of ARV prophylaxis to HIV-positive pregnant
women, globally, 1996 - 2008 (UNAIDS, 2009 AIDS epidemic update)

Reported TB incidence, all cause mortality and ART
uptake Botswana, 1990 - 2007.

ART bends the epidemiological curves associated with HIV:AIDS deaths have begun to decline worldwide3 and there havebeen decreases in overall adult mortality, as well as infant
and under-five mortality.4 ART has also led to fewer children
being born with HIV and fewer AIDS-related orphans.5
Further, ART helps decrease the emergence of opportunistic
infections such as tuberculosis (TB), with a 60% reduction

4

in TB incidence among people receiving ART documented
in some ART programmes as well as steep declines inmalaria.6,7 People are less sick and thus less likely to require
hospitalisation. And new research shows that treatment isprevention: one recent study published in the Lancet found a
92% reduction in HIV transmission in Africa among couples inwhich one partner was HIV-positive and on ART.8

Rationing Treatment is
Irrational in a Growing
Epidemic.

1. Limiting Treatment Slots Means
Choosing Who Lives and Who Dies.

“© Pim Ras

We were told we couldn’t put more patients on ARVs because
the funding was insufficient. It’s really hard seeing a patientcome here to be told ‘we can’t help you.’ We don’t know how
many of them died or what happened to them, unfortunately.
– Dr. Margie Hardman, physician in PEPFAR-funded clinic,
South Africa.

”

ART has had a dramatic positive impact on reducing mortality,
measurable at the community level. At the 2010 IAC in Vienna,
MSF presented data from rural Thyolo, a district of Malawi, where
MSF works with the Ministry of Health to provide HIV services atthe primary health care level. In Thyolo district, universal accessto treatment and care has been reached – meaning at least eightout of ten people in need receive ART – and between 2000 and
2007, a 37% reduction in the district’s death rate was measured
through death registers, coffin sales and church funerals. Deathrates decreased over time as ART coverage increased. An
estimated 10,156 deaths were averted in the districtii over aneight-year period.19

Registered deaths at five traditional authorities and relationship to enrolment
in HIV/AIDS care and ART, 2000 - 2007, Thyolo District, Malawi

Treatment Reserved for
Those Who are Almost
Dead

But decreased funding for ART is resulting in fewer treatment
slots being available for an increasing number of people in need.
Clinicians and nurses in some instances are faced with theagonising decision that comes with rationing care: choosing whogets to live and who doesn’t. An example of this in Uganda serves
as an alarm bell for what MSF is witnessing in several countries
across sub-Saharan Africa.20 A letter from the US Centers for
Disease Control received by PEPFAR implementers in Ugandain October 2009 states that there will be no funding increases
despite rising needs. And therefore, treatment providers should
only enroll new patients on ART if people in the treatment
programme die or are lost to follow-up. The letter outlines an“equitable system of triage” for ART slots, reserved only for the
sickest patients, pregnant women, children, patients co-infectedwith TB and family members of those on ART. Rationing care will
result in the waiting line for treatment getting longer as people
paradoxically are forced to first become sick enough to be eligible
for treatment. And many people may be lost to follow-up in themeantime.

2. Delaying or Deferring Treatment
Leads to Transmission, Illness andDeath.

“

Most of the people are still healthy when they initiate[treatment] now. It is easier for them to pick up faster, to get on
ARVs. Before, they had to delay taking ARVs as they first had totreat TB or other opportunistic infections.
– Magerard Mochesane, Nurse, MSF Lesotho”

Providing people with ART earlier, when their CD4 cell count iii
is higher, keeps them healthier and out of hospitals, allowing
them to live more productive lives, while improving their chances
ii Thyolo district population: 592,630 in 2007.
iii The CD4 cell count is a measure of the immune system’s robustness.

5© Brendan Bannonof survival. Earlier initiation at higher CD4 levels also supports
earlier viral suppression, and thus reduces the likelihood oftransmitting the virus to other people.21 Further, an MSF study
presented at the IAC found that people starting treatment at lower
CD4 levels have higher rates of treatment failure, thus needing
to switch to newer, more expensive drug regimens.22 Early
treatment thus makes clinical, social and economic sense.
In wealthy countries, people are initiated on treatment when
their CD4 count drops to 350 cells/mm3, or earlier. In developing
countries, in contrast, people have typically only been started ontreatment when the disease has progressed significantly, at aCD4 count of 200 cells/mm3, or below. In late 2009, WHO revised
its guidelines for initiation, moving the recommended thresholdfor developing countries from 200 to 350 cells/mm3, in line withwealthy countries.23
Earlier initiation is feasible in HIV-endemic countries. Data
presented at the IAC from MSF’s ART project in Lesotho supports
earlier initiation: patients initiated earlier were less likely to die
and/or be lost to follow-up; hospitalisation rates were higher forpatients initiated at a CD4 count below 200.24 Providing treatment
earlier thus frees up beds and limited staff time for other patients.
However, such a policy change, while clinically sound as well as
cost effective,25 is politically problematic: changing the eligibility
criteria for treatment initiation also means that more people – 14
million instead of 10 million – are eligible for treatment, of whom
only four million receive it. Addressing the ten-million-person
treatment gap will demand vastly increased resources for ART
scale-up.

3. Failing to Ensure a Stable Drug Supply
Means Viral Load Shoots Through the
Roof.

With ART,
Sharing Isn’t Caring.
© Michael Goldfarb/MSF“

If the drug is continuous dose, then you can’t miss it. But
when they tell you that the drugs are not there, you have tocome back and it creates a lot of worries.
– Catherine Mango, PLWHA, Kenya”

For ART to work, people must adhere to their treatment as muchas possible – this means taking the right drugs at the righttime. People on ART in endemic countries are as adherent totheir treatment regimens as those in wealthy countries.26 But
if treatment is interrupted or not taken correctly, the virus is nolonger adequately suppressed and thus allowed to multiply andweaken the immune system. People rapidly become sick again,
and infections such as TB emerge and spread in the community.
Additionally in such scenarios, drug-resistant strains of the virus
can develop and be transmitted to others.
A commitment to adherence presupposes that there is a steadysupply of ARVs available to patients. But with unstable funding
come unstable drug supplies and even stock-outs. As a result,people may share ARVs, with devastating effects. Health workers
manage supply shortages in various ways, either by switching6

patients to other medicines that may have more side effects, byproviding different dosages, or by giving patients ARVs for shortertime periods. The latter increases the burden on overworked
health staff as well as on patients, who often have to travel long
distances to reach clinics.27
MSF has witnessed an increasing number of supply disruptions
in sub-Saharan Africa since 2009. In 2009 and 2010, MSF has
had to regularly provide emergency supplies to public clinics
in Mozambique, Malawi, Uganda and the DRC that previously
relied on international donors for ARVs.28 After the Malawiannational treatment programme began experiencing stock-outs
in 2009, MSF purchased ARVs for €375,000 to avoid treatment
interruptions for its patients in Chiradzulu district, covering theneeds for nine months.29 Beyond MSF clinics, the organisation
has been approached to provide emergency buffer stock toministries of health and international and local NGOs in Malawi,
Zimbabwe, the DRC, Kenya, Uganda, Guinea, and the Central
African Republic.30

The Vicious Circle
Returns

4. Breaking the Promise of ART Means
People Won’t Come Forward to Get
Tested.

© Brendan Bannon“

I would call it a moral betrayal because we will have failed
our patients, who were told to get tested. And all the ones who
tested positive, we promised them we’d provide treatment.
– Dr. Eric Goemaere, MSF South Africa”

Despite persistent social stigma, people have come forward to
get tested for HIV because of the increasing awareness that lifeprolonging treatment is available to those who test positive. This
promise of ART has been the cornerstone of reaching those inneed through voluntary counselling and testing.
But if people are turned away from clinics that are forced toration care, and unstable ARV supplies and stock-outs becomecommonplace, the promise of ART availability will have beenbroken. As this news spreads through communities, there will
be little incentive for people to get tested. It has taken PLWHA
groups and health workers years to establish a sense of trust incommunities and to encourage people to know their HIV status.
It may take even longer to re-establish the promise of ART if it is
lost.

7

The Next Generation of
AIDS Babies?

5. Slowing AIDS Efforts Means Kids
With AIDS Become Even More of an
Afterthought.

“© Joanne Wong/MSF

Children were the last to come onto the radar when it comesto treating HIV/AIDS, and they will be the first to fall off. We
need to make sure that the response to AIDS for children
becomes mainstreamed.
– Dr. Myrto Schaefer, Paediatric HIV Advisor, MSF”

Children in developing countries have consistently lagged behind
adults when it comes to HIV/AIDS treatment and care. First, child
infections are almost entirely avoidable: successful measures toprevent mother-to-child transmission of the virus (PMTCT) havevirtually eliminated paediatric AIDS in wealthy countries, where itis estimated that there were fewer than 200 new child infectionsin 2008.31 Although there has been an improvement in accessto PMTCT interventions for women in poor countries,32 nearly
half a million children were still newly infected in 2008.33 WHO
now recommends improved PMTCT protocols with HIV-positive
pregnant women receiving full ART prophylaxis throughout the
pregnancy and breastfeeding period. But without funding toincrease outreach to expectant mothers and implement such new
protocols, it is unlikely the number of babies born infected will
decrease.
Second, because the market for paediatric AIDS treatment anddiagnostics is concentrated in countries with limited ability to pay,
the pharmaceutical industry does not prioritise the developmentof improved and adapted paediatric medicines and tests – there
are far fewer options for children than for adults. Such a small
and fragile market will be particularly vulnerable to funding
instability, with a number of priority paediatric formulations
identified by WHO likely not to be developed unless there isincreased funding, or other incentives are created. And much lesspriority will be placed on developing urgently-needed diagnostic
tests that would allow treatment providers to immediately see
whether the virus has been passed from the mother to thenewborn or not. Without such a tool, treatment providers must
continue to perform testing that requires samples to be sent away
to laboratories, with the risk that babies are lost to follow-up in
the meantime. Decreased funding for AIDS will send a signalthat paediatric AIDS is even less of a priority, which will havedevastating effects on the effort to improve treatment and care forthe youngest patients.

8

Why Quit When Things
Were Just Taking Off?

6. Limiting the Number of Facilities
Offering ART Means it’s Harder to Reach
People in Urgent Need.

“

People have to come more often to the clinics. Some of them
are not from around here. They use vehicles to come to theclinic. If you don’t have the transport you will have to put a lotof effort into how to get the fare. If you are told to go home andcome back, then it will force you to look for another fare to comeback to clinic. If you’re working, it will make you lose some ofthe days that could be used for getting food for your children for
example. So it makes you uncomfortable.
– Catherine Mango, PLWHA, Kenya”© Brendan Bannon

Bringing AIDS treatment close to where people live facilitatestreatment scale-up to those in need and reduces the risk oflosing patients to follow-up. It removes the need for patientsto travel longer distances, which can be both expensive anddisruptive to their lives, especially for the very sick. In Lesotho,
more than 80% of primary health care facilities offer ART, andin Tete, Mozambique, care has been decentralised further tothe community,34 with significant benefits in terms of improved
retention in care.
Further, medical tasks are ‘shifted’, allowing nurses to perform
duties previously reserved for doctors, and lay health workers
with specific training to perform functions otherwise reserved fornurses. In one of MSF’s longest-running treatment programmes,
in Khayelitsha, South Africa, 400 patients were initiated on ART in
2003, whereas after decentralisation and task shifting to nurses,
4,000 patients were initiated in 2009. Data presented at the
IAC from MSF’s treatment project in Malawi shows that nursedelivered, decentralised care is leading to treatment outcomes as
good as those of centralised care.35
Further data presented at the IAC shows that a new, simplified
approach to decentralised care is being implemented by MSF in
Malawi and Mozambique: stable patients who have been on ART
for more than one year, are 95% adherent, have CD4 counts above
350 and show no signs of opportunistic infections go for medical
checkups only once every six months.36 They are provided with
ARV refills in the interim and are followed for clinical evaluations
every two to three months by health surveillance assistants –health workers who have received training for six weeks. Thisapproach has reduced stable patient consultations by 25%, freeing
up medical staff time for cases requiring more attentive careand follow-up, or for new patients. It has thus far shown goodoutcomes, and could be a way to reduce the number of people lost
to follow-up.37
With external resources, Lesotho was able to make ART available
in more than 80% of primary health care clinics.38 Kenya andMalawi both have national plans to achieve universal access by
2012 through increasing the number of facilities offering ART.
Kenya plans to increase the number of public sector facilities
offering ART from 15% to 40%.39 Malawi started with nine sites
providing ART in 2003, jumped to 224 in 2009, and now plans tocapacitate 65% of existing facilities to provide ART.40 However, bothcountries are facing funding shortfalls, with little more than half of9the funding needed. Whether ART will be decentralised depends on
the success of proposals to the GFATM and how well the GFATM isfunded.
But putting a stop to ART scale-up by reducing funding will
mean that fewer facilities offer ART. This will freeze availabilityof treatment, in an effort to ration care by placing limits on thenumber of access points. In many countries, decentralisation
has yet to happen, and ART is only initiated by doctors, only at
centralised facilities, and only accessible to those lucky enoughto live nearby, or those who can afford transport. Without
decentralisation, no treatment or financial gains can be madein freeing up medical staff time, thereby reducing the number ofpatients that can be reached and slowing ART scale-up.

Shutting Down the
HIV/TB One-stop Shop
Before it Even Opened.

7. Slowing Down the Integration of HIV
and TB Care Means Patients Will Slip
Through the Cracks.

“© Stefan Pleger

HIV and TB treatment and care must go hand in hand.
Unfortunately, in most places, HIV and TB are still treatedseparately, even though it’s one and the same patient who
suffers from both diseases.
– Dr. Frauke Jochims, MSF”

Tuberculosis remains the primary killer of people living with HIV/
AIDS: an estimated one quarter of the people who died of TB in
2007 were co-infected with HIV – nearly half a million people.41
Providing a package of TB and HIV services together in one clinic
is critical to tackling the dual epidemic, but today, this integration
has only barely begun to be implemented.
Data presented at the IAC from two MSF programmes where TB
and HIV treatment and care have been integrated shows goodresults. In Swaziland, where HIV prevalence among adults is26%, eight out of ten HIV-positive people are also co-infected with
TB, and drug-resistant strains of TB (DR-TB) are significantly
on the rise, posing major challenges to communities. In therural Shiselweni region, MSF provides integrated HIV/TB care in
17 clinics. Case detection for TB improved greatly, from 58% to
87% during 2009, and DR-TB detection and treatment initiation
doubled from 2008 to 2009.42 A similar approach was taken by
MSF in Lesotho, where undiagnosed TB was the number one
killer of people living with HIV. TB and HIV care is provided atprimary health centre level by nurses trained in HIV/TB care,including ART initiation, and HIV/TB lay counsellors are trained
to give adherence support for both therapies. Because of highrates of HIV/TB co-infection, an aggressive screening process was
put in place. In 2008, 93% of TB cases were tested for HIV (78%
positive), of whom 81% received ART. The TB treatment successrate in co-infected and non-co-infected patients respectively was
65% and 77% in 2007 and 70% and 79% in 2008.43
These data show that decentralised, integrated TB/HIV care atprimary care level improves access to treatment and outcomes,

10and is a successful way to reach people affected by the dual
epidemic in rural high-prevalence settings. However, a reduction
in funding means that all services may suffer, further decelerating
efforts to integrate HIV and TB treatment and care, allowing cases
to continue to go undetected and TB to spread, posing a strain on
already overburdened health clinics.

It’s the Same Patient© MSF

8. Choosing Between Maternal & Child
Health or AIDS Means Making a Fatal
Choice.

“Primary care clinics are the pillar of most public healthservices in Africa. Inevitably, when you support the clinic, you
support it in all its aspects. At population level in areas such as
Thyolo in Malawi, or Khayelitsha in South Africa, we measure
not only an HIV/AIDS-related mortality, but in the whole area,
we see the entire mortality going down, which includes ofcourse the maternal mortality and the paediatric mortality.
– Dr. Eric Goemaere, MSF South Africa”

There has recently been a major move among donors to focus
more on maternal and child health, and this has been used as
one of the explanations for reductions in support for HIV/AIDS
interventions. But in Africa’s AIDS-devastated countries, childand maternal mortality is inextricably linked to HIV/AIDS. The
main cause of death in women of childbearing age is AIDS, andover 40% of deaths of children under five in Swaziland, Botswana,
Lesotho, Zimbabwe, Namibia, and South Africa are because of
HIV/AIDS.44
Addressing HIV/AIDS has measurable positive benefits in other
health areas. 45, 46 In particular, PMTCT programmes can leadto more women receiving maternal care. In MSF’s treatment
project in Thyolo, Malawi, PMTCT services, along with support toreproductive health care, led to a near doubling of the proportionof women giving birth in health centres, from 22% in 2006 to 41%
in 2008.47 In South Africa’s Western Cape province, there was a
54% reduction in under-five child mortality at population level
after comprehensive HIV/AIDS services were introduced. And
after the introduction of PMTCT services in Khayelitsha, South
Africa, MSF observed reductions in infant mortality from 43 per1000 live births in 2001 to 30 per 1000 in 2007.48
MSF began integrating HIV/AIDS treatment and care into primary
health care in some projects in 2005, after having provided
HIV treatment and care in vertical projects since 2000. Data
presented at the IAC comparing treatment outcomes from 20032009 in integrated and vertical programmes across nine countries
in sub-Saharan Africa shows that outcomes in integrated
programmes are similar to those in vertical programmes,49 thus
reinforcing the feasibility of providing ART as part of the basic
health care package.
Donors who now want to shift the focus away from supporting
HIV/AIDS treatment and care to maternal and child health are
creating false choices and perpetuating a futile and divisive
debate: we are talking about the same people. More funding
should be allocated to global health rather than withdrawing
support from one area to fund another.

11Second-Class Carefor the Poor?

9. Continuing to Use Drugs With Side
Effects Means Relegating Patients to
Second-Class Care.

“

On d4T, patients were getting large fat depots on their body.
People feel better with TDF now, complaining less of side
effects. As they vomit less, they don’t need to repeat doses of
their medication.
– Magerard Mochesane, Nurse, MSF Lesotho”© Brendan Bannon

People on AIDS treatment in developing countries should haveaccess to newer, better treatment.50 The drug stavudine (d4T),
which is one component of the most-commonly-used ARV
combination in developing countries, has significant side effects
for patients. In MSF’s project in Kigali, Rwanda, 16.6% of patientsneeded to be switched from stavudine after a median duration
on treatment of 1.5 years because of side effects.51 Increased
toxicity-driven switches associated with stavudine have been
documented in MSF programmes in South Africa52 and Lesotho.53
In place of stavudine, WHO now recommends patients ideallyreceive tenofovir (TDF)- or zidovudine (AZT)-based regimens.
These are generally better tolerated, improving adherence andhelping people stay on a first-line of treatment for as long as
possible, before needing to be switched to more costly secondline drugs.
The most affordable generic TDF-based first-line regimen still
costs $141 per patient per year (ppy). This is more than double
the price of the older stavudine-based regimen ($67 ppy). History
has shown that if the more expensive newer combinations arepurchased in large volumes from multiple producers, prices will
come down significantly.
Less-toxic drugs are not only better for people living with AIDS,
they also cost less over time when one factors in the cost of
managing side effects: fewer clinic visits, less need for testing
and fewer hospitalisations. MSF’s treatment project in Lesotho,
which has the third highest HIV-prevalence rate in the world, hasbeen providing TDF-based first-line ART since 2008. A costeffectiveness analysis presented at the IAC of alternative first-line
ART regimens based on primary clinic data from Lesotho showedthat TDF would be cost-effective compared to d4T with anticipatedprice reductions.54 These results are reassuring for countries
considering introducing TDF in first-line ART.55

12

Failing treatment :a Return to Death Row?

10. Cutting Back on Funding for
Treatment Means Sacrificing Long-term
Survival.

“

We have quite a lot of people who have prolonged their lives
thanks to ARVs, and we need to keep them on ART for the rest of
their lives.
– David Some, Clinical Officer, MSF Kenya”

HIV/AIDS is a life-long disease and ensuring people’s long-term
survival on ART requires sustained commitment. Similar to otherchronic diseases, people who have been on ART for several years
inevitably need to switch treatment regimens to stay alive as drug
resistance emerges. It is essential to switch people to a different
drug combination at the right time – waiting until they become
sick again may be too late.

© Cristina De Middel

In wealthy countries, a 20-year old starting ART can expect to live
another 43 years on average.56 But in HIV-endemic countries,
there are two fundamental challenges to ensuring long-term
survival: first, treatment failure is a hidden problem, because
there are no point-of-care tests to determine a patient’s viral load,
which is the most important and sufficiently early measure oftreatment failure. Today, viral load testing requires access to hightech laboratory equipment that is often only found in countries’
capitals. Further, viral load testing is expensive (up to $80 per test)in part because of company monopolies on the technology.57 Thismeans that treatment providers struggle with trying to diagnose
when a patient is failing their treatment and may wait until clinicalsigns of illness recur.58
Second, switching people to newer drugs is very expensive,as these cost between three and seven times what a first-line
regimen costs today.59 And for patients who are already beginningto fail on their second-line regimen, options are extremely limited,with prices high and availability low – a third-line combination
costs $3,200 per patient per year – seven times more than thecheapest second-line, and 48 times more than the cheapest firstline.60

Price comparisons of first-lines, second-lines and possible third-lines.

Data presented at the IAC from 28 MSF-supported treatment sites
in Africa and Asia underline the fact that these two difficulties
combined mean delays in switching patients. Of 67,601 patientsin the study, 18% met criteria used to define treatment failure
after a median of 12 months on ART, but only 1.4% had switchedregimens after nearly 26 months on treatment. Patients in rural
areas in particular were less likely to switch regimens when they
were failing, and had lower CD4 counts when switched.61
A commitment to providing universal access necessarily means
providing people with the treatment they need to stay alive in thelong run. Retreating from AIDS funding means shutting the door
on treatment for life.

13

What needs to happen
The first decade of providing ART in resource-poor countries has
shown that treatment is effective and has a dramatic impact on
people’s lives and communities. Now is not a time to throw awaythat progress. This means not only committing the funds needed
to continue scaling up ART, but also to close the quality gaps thatpersist between AIDS treatment in rich and poor countries. It
means adhering to WHO guidelines to start ART earlier, monitor
patients’ viral loads to ensure optimal treatment, and provide
people with less-toxic drugs that improve treatment outcomes, aswell as providing access to second- and third-line regimens andimplementing PMTCT protocols. And it also means supporting
models of care that have proven to work, and not pitting HIV/AIDS
against other health priorities.

affected by 2016. Overcoming patent barriers for newer
generations of AIDS drugs will require a range of different
solutions: for example governments must make full use of TRIPS
flexibilities, including routine use of compulsory licences andbe supported by donor countries in doing so;64 where possible,
civil society and other groups must challenge inappropriate
patents before or after they are granted; companies can increase
access by putting their AIDS patents into the newly-established
Medicines Patent Pool;65 and wealthy countries should refrainfrom pressuring developing countries to include intellectual
property measures that go beyond what the TRIPS Agreement
requires, such as in the current free trade agreement undernegotiation between India and the EU.66

Although costs will increase in the short-term, these will be offset
by the long-term payoff of healthier and more productive people.
In light of the financial crisis, donors may be tempted to walkaway from their commitments to provide universal access to AIDS
treatment, turning their backs on clinically-sound interventions.
But these policies are short-sighted and fail to take into accountlong-term payoffs, including savings in economic terms, aswell as increased quality of life and quality outcomes. Donors
must close the $20 billion funding gap at GFATM’s October 2010
replenishment conference, and PEPFAR must put an end to flatlining its budget.

In times of growing need, new and sustained sources of funding
must be identified to help fill some of the funding gaps for HIV/
AIDS, as well as other global health priorities. A number ofinnovative financing mechanisms are being discussed to recoup
some of the losses governments experienced as a result of theeconomic contraction and the bank and industry bailouts. One
such proposal is a financial transaction tax currently being
promoted by the European Union. But a share of the funds raisedby such a levy must be earmarked to global health issues such as
nutrition, HIV/AIDS treatment and tuberculosis research. For HIV/AIDS specifically, there are compelling reasons to support such atax: substantial and sustained funding is needed to scale up ART
and end the AIDS epidemic, and AIDS can’t be victim to changes
in political and financial support.

With the number of people in need of ART projected to reach as
many as 55 million by 2030,62 we must ensure that donor funds
are used to benefit the lives of as many people as possible –prices for newer ARVs must come down dramatically. Genericcompetition in countries where ARVs were not patented is what
led to the cost of ARVs plummeting by more than 99% over thelast decade, in large part making ART scale-up possible. But
the World Trade Organization’s TRIPS Agreement63 is making
the patenting of medicines more widespread in key production
countries, such as Brazil and India, with all developing countries

HIV/AIDS continues to be a global emergency requiring an
emergency response. But barely four years after promising
to provide support to put all people on treatment, donors havebegun questioning the affordability of universal access. The
epidemic already claims more than two million lives each year,
but a reduction in support will add many more lives to this glaring
statistic. It is not too late for donors to re-engage.

© Brendan Bannon

14

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Trade-related Aspects of Intellectual Property Rights
In order to serve health needs, countries can override patents in an entirely lawful manner by issuing what is called a compulsory license. A compulsory license allows country A toproduce, or to import from country B, a more affordable generic version of a drug that is under patent in country A. This can be done without the permission of the patent holder, whomust nevertheless be paid royalties.
The Medicines Patent Pool Foundation is a voluntary licensing mechanism to reduce ARV prices, increase access and spur the development of new ARV formulations. More info
available at: www.msfaccess.org/main/access-patents/make-it-happen-campaign/More info on the India/EU FTA available at: www.msfaccess.org/main/access-patents/free-trade-agreements/

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