Access to Treatment for HIV in Developing Countries

International Seminar on Access to Treatment for HIV in Developing Countries
5-6 June 1998 London, UK

Learning from experience: Tuberculosis and HIV

Dr Anton Pozniak
Kings College Hospital
London, UK

Lessons from Tuberculosis
Like HIV, tuberculosis is a chronic illness that eventually leads to death. There are nearly eight million new cases of TB per year and this is set to rise to 12 million new cases per year by the year 2005. Someone dies from tuberculosis every 15 seconds. In spite of this there are curative treatments which have been known since the late '40s and there are now treatment regimens that can be taken for six months with high cure rates. Like HIV the treatment is complex, requiring a combination of therapy but unlike HIV the treatment for TB is only taken for a finite length of time.

Treatment
There is a disproportionately small amount of money spend on tuberculosis in the world compared with the numbers of deaths from TB and it is only in recent years that efforts have been targeted again towards trying to control this disease. There are many drugs to choose from to treat TB and by using set regimens containing rifampicin, therapy need only be taken for six months. However many countries in the world cannot afford these types of regimens and have to rely on longer courses of treatment with less potent drugs. For most cases of tuberculosis, it costs US $26.00 to cure a case. For one year's treatment of HIV, it is around USD $8,000 - $10,000. Because multiple combinations of therapy need to be taken for tuberculosis and most of this therapy is manufactured elsewhere, there is always a problems with drug shortage because of cessation of production or manufacturing problems. There are also problems with importing drugs and drug supply at country or local level.

Drug supply
Out of the eight million cases per year of TB, only five million get any sort of treatment and only 500,000 receive directly-observed therapy (DOTS) which has been the thrust of WHO's recently campaign to control tuberculosis.

Compliance
Because of the complexity of TB treatment, WHO have recommended DOTS. Outside of DOTS programmes, compliance rates vary from country to country and can be as low as 25 - 40 percent.

Role of private practitioners
Private practitioners, especially in countries like India, are the main providers of antituberculous chemotherapy and do not always follow international or national guidelines and end up prescribing and giving inadequate therapy.

Multidrug resistance
Like, TB, HIV multiple drug therapy requires to be taken long-term, even life long, and the drug therapy has to be monitored with sophisticated blood tests. The drug supplies for therapies must be assured because if there is an interruption in this then drug resistance, often multiple, can result. National guidelines need to be in place and the finance for drugs and laboratory and community support needs to be guaranteed. Transmission of resistant HIV has already been well-recognised. Although the short-term clinical effects of HIV antiretroviral therapy have been dramatic, there are also patients who have virologically failed and require more sophisticated treatment and specialist knowledge.

Discussion:
The purpose of Dr Pozniak's presentation is to show that lessons from TB treatment can be applied to HIV and to alert people to some of the problems of just providing drugs. There are problems with ARVs and we must consider all the steps involved with treatment or we could be in big trouble in two years time.

In addition, a major problem for most people with HIV in the world is TB. For example 45% of HIV positive people in India have TB. This is an example of a disease that has a cure but little is being done about it. He cautions about throwing a lot of funds at AIDS when the problems of resistance and stable drug supply have not yet been sorted out for other diseases such as TB.

Dr Pozniak considered that WHO should focus on:

Blood safety (he drew attention to recent problems in Kenya and India).
Preventive programmes, especially educating people on how HIV is transmitted.
Good protocols on ARV use. In the South, some people can obtain ARVs, so good protocols are needed showing how ARVs should be used effectively or programmes providing ARVs could go badly wrong resulting in many problems, including multidrug resistant HIV.

He noted that the USA has recently held the first Antiretroviral Salvage Conference only three years after protease inhibitors were first available in the country. In Australia, a total of six drugs are being given to people with HIV for whom other drugs have failed after one or two years, which is simply not affordable in most countries. The cost of ARV treatment is prohibitive. It costs around US$30,000 per HIV positive person per year, which globally is not affordable.

Other important issues were brought up in the discussion:

Frustration was expressed about the fact that developing countries have so many health problems, such as TB, malaria, maternal and child mortality, and diarrhoeal diseases. Are these countries expected to wait and solve these health problems before putting funds into HIV treatment? More public funds are needed for health in general which should be diverted from inefficient interventions, such as the military.
DOTS Programmes in Latin America are generating epidemics of Multi Drug Resistant TB. This is occurring even under the best conditions for treating TB.
Before AIDS, TB had not been well funded. For example, WHO has spent 10 years trying to eradicate TB but in 1990 there was only one staff member assigned to the task. If funds could be raised for treating HIV/AIDS, the outcome would surely be good for TB also. Most of the funds for AIDS are additional health care funds.
Comparing the cost of treatments is a difficult process and can be misleading if not done with great care. Rrational use of public funds should be considered paramount.