Remember the shock campaign in 1987, icebergs and the tombstone? A time when we started to hear how HIV/AIDS was becoming an epidemic and a certain death sentence to any who were unfortunate to be infected.
23 years later, HIV/AIDS is still a huge global disease but no longer causes the fear so evident in those earlier times; we have become almost blasé about it, a certain lack of concern has crept in. This may be due to the discovery and availability of ARVs (Antiretrovirals). Those who are HIV+ and on ARVs can now live a long, relatively normal life.
“Have halted by 2015 and begun to reverse the spread of HIV/AIDS”.
In 2005 this additional goal was set:
“Achieve, by 2010, Universal Access to treatment for HIV/AIDS for all those who need it”.
Uganda has had significant success in the fight against HIV/AIDS. Adult numbers testing positive have reduced from 15% in 1990 to 5%. Today 1m Ugandans are HIV+, down from a high of 1.5m in the mid-nineties. The annual death rate which peaked in 1999 at 120,000, was 80,000 in 2007. However some now worry that downward trends have stalled and indicators may be on the rise again; 130,000 still become infected each year. This continued growth in numbers infected and soaring costs of treatment mean that Uganda will find it impossible to attain the goal of Universal Access by 2010 and may even struggle to achieve it by 2015.
Clinical trials show that provision of ARVs can halt and reverse the effect of HIV/AIDS on an individual’s immune system, reducing death rates and the impact of opportunistic disease. Immune strength is measured by a blood test in which a certain type of cell is counted; a CD4 count. In December 2009 WHO issued guidelines suggesting that antiretroviral therapy (ART) should be started when this count falls below 350, rather than the previous indicator of 200. In Uganda that means those needing ART rises from 300,000 to 750,000.
Uganda found it difficult enough to ensure treatment for all at the 200 count. Annual treatment cost is estimated at $500 per patient; if all were treated the total required would exceed $375m, more than the total annual healthcare budget. Uganda relies on the Global Fund and PEPFAR for more than 95% of its required funding and both of these are now talking about flat-lining rather than increasing funds due to the global economic downturn.
Poor implementation management and lack of funding has led to stock-outs, in which the drugs become unavailable. This is very serious; it is essential that once treatment has been started that it should be continued; stopping or even having a break in the treatment routine can lead to an increased risk of drug resistance and the need to move the patient from lower cost, first-line drugs to significantly more expensive second and third-line treatments. Such concerns lead some clinicians to consider not enrolling any new patients onto ART programmes, trying to make sure that they can adequately cover those already enrolled.
In the short-term, it’s hard to see how ART enrolment numbers will increase, leading to a negative impact on key indicators and Uganda will start to slip back from the good progress made. So what can be done?
1. The Global Fund needs to convince donor countries to increase funding and meet the promises made when setting the goal of Universal Access.
2. Uganda Ministry of Health should endorse findings from the DART clinical trial which recommends that those testing positive are enrolled on ART sooner and without the need, during the first 2 years, for expensive CD4 tests.
3. The MoH should amend its policy to allow clinical officers, nurses and midwives to be trained and empowered to administer and monitor ART, “task-shifting”.
4. The Government should take measures to ensure full production of ARVs at the Quality Chemicals Industries factory, at the lowest possible price, cost without margin.
We must meet promised funding levels, reduce treatment costs and increase available clinical resources.