Anthony Harries, MD, offered a powerful overview of the history of the global AIDS response from the vantage point of his work over more than a decade in the small African country of Malawi. He spoke at the plenary session of the Conference on Retroviruses and Opportunistic Infections (CROI) in Boston Sunday.
Malawi is a country of only 134 million people with a nominal GDP per capita of $280, and $50 per person of annual spending on health. The HIV prevalence is 14 percent translating into one out of every seven adults infected with HIV. Thanks largely to HIV and other infectious diseases like tuberculosis, life expectancy is 44 years. Harries spoke about the early years of the epidemic, when HIV was taking its deadly toll on health care workers and school teachers. One-third of the women’s beds at the hospital where he worked were occupied by young women between 15 and 25 years old who were dying of AIDS. Most adults who presented for care had Stage IV AIDS and 90 percent were dead within 12 months.
The 2000 International AIDS Conference in Durban jump started the global response and by the summer of 2001, Malawi began to develop and implement a plan for HIV treatment scale up. The country would receive a grant from the newly created Global Fund to Fight AIDS, TB and Malaria the following year.
As of September 2010, there were nearly 238,000 people in Malawi on antiretroviral therapy (ART). Now only 10 percent of persons with HIV presenting for care have late stage HIV disease. In a country with poor infrastructure with no registered death certification process, Harries and others have measured the impact of ART scale-up by looking at trends in funerals and coffin sales.
While progress in ART scale up has been dramatic and lifesaving, Harries noted that there has been only minimal progress in preventing new infections – with a steady 75,000 new infections every year in Malawi. There is poor uptake of prevention of mother-to-child transmission interventions with slightly less than half of all pregnant women being tested fir HIV. There are also high rates of death and loss to follow up for those beginning ART. Lack of access to CD4 technology is a huge problem – only 54 of 406 ART sites in the country have access to a functioning CD4 machine.
Harries made a bold proposal for moving forward in Malawi and challenged the audience about whether it really makes sense to wait five more years to see the results of randomized controlled trials evaluating so called “test and treat.” He called for universal testing of all pregnant women in Malawi with those testing positive immediately receiving ART for life. He noted that the promise of such a strategy could be an AIDS free generation by 2015. This policy would address a variety of issues including Malawi’s high fertility rate of 5.6 children, lengthy breastfeeding period, the reality of weak health infrastructure and the lack of CD4 capability. This policy would be simple to implement, protect sexual partners of women, reduce tuberculosis, and with the right regimen, also treat hepatitis B. Ten percent of the population of Malawi is infected with hepatitis B.
Harries noted that if this policy were shown to be high impact, it should be expanded to all who test positive. He also called for the promotion of HIV education and behavior change and the use of pre-exposure prophylaxis or microbicides for uninfected partners.