Real world challenges to deploying effective HIV prevention and treatment

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Dr. Peter Piot (far right), director of the London School of Hygiene and Tropical Medicine, gives his plenary presentation at the 2011 International AIDS Conference in Rome.

There was some consensus among the Tuesday opening plenary speakers at the 2011 International AIDS Conference in Rome – there are many challenges to effective HIV prevention and antiretroviral therapy (ART) deployment.

Dr. Peter Piot, director of the London School of Hygiene and Tropical Medicine, discussed the AIDS response and the need for a long-term view. In terms of the exciting prevention science released in the recent months, “If we had had these tools ten years or even five years ago when AIDS budgets were expanding and AIDS leadership was at an all time high, I think we would see far less AIDS deaths and far fewer people living with AIDS than we see today,” he said.

“Twenty years from now there will still be about 1 million new infections even if we take into account major impact of treatment on new infections,” Piot said, adding later that about half of recent infections are attributable to contact with someone with early HIV infection. There also will still be about 1 million deaths per year by 2020 even under a very favorable scenario, Piot said.

“We shouldn’t forget these figures and they may be wrong by some factor… [but] it is highly unlikely that HIV will be eliminated in these timelines… It’s time to take a long-term view while remaining in emergency mode and very alert,” he said, stressing that the current economic crisis is taking it’s toll and that “you can’t control AIDS on the basis of a single fiscal year every time – we need long-term commitments.” Specifically, he called for customized responses for epidemics at the local level (he anticipates that prevention efforts in that regard will vary greatly across populations), investment in local capacity to do so, new alliances and leadership in this effort, a strengthened investment in research and development, and broad effort toward optimization, efficiency and synergies.

One of the top priorities Piot mentioned was the need for innovation in delivery of services. As we scale up ART, appointments with health care providers will go through the roof and there is a need to come up with alternative options, Piot said. For instance, home-based care in Uganda has shown to be just as good in terms of survival as clinic-based care.

Both Piot and Dr. Susan Kippax, of the Social Policy Research Centre at the University of New South Wales Australia, made a point to distinguish prevention interventions’ efficacy (at the individual level) from effectiveness (at the global level), and that efficacy in randomized, controlled trials simulates an ideal environment. Trials are needed, Piot said, to evaluate effectiveness in the real-world setting of various combinations of the different prevention tools in different social environments to determine what will work best and under which circumstances.

Dr. Serge Eholie, Professor of Tropical and Infectious Diseases University of Abidjan Medical School in the Ivory Coast, detailed the various and complex challenges in HIV treatment and care in resource-constrained environments. With an accompanying photo of a small house supported on one side by a stack of old tires, he coined financing sustainability the “Achilles heel of ART programs” with 80 to 95 percent of funding coming from international donors. He called for governments of affected countries to take on as much responsibility as possible for financing their own epidemics – the packed audience responded with a round of applause.

The other challenges he mentioned included:

  • Patient retention (25 to 30 percent of HIV patients are lost to follow up between one and two years)
  • High ART mortality especially during the first year following treatment initiation and addressing the need to start ART earlier (But how much earlier?)
  • The cost of second-line treatment and increasing numbers of HIV-infected patients failing first-line regimens.
  • Challenges in implementing the World Health Organization revised 2010 guidelines for adults and adolescents.
  • Human resources issues like brain drain and motivating health care workers
  • And “out of control” humanitarian crises like the 2010  Haiti earthquake, and ongoing food and drought crises in East Africa.

Eholie also stressed the need to address ART coverage and challenges for an aging population, noting that there are 3 million people living with HIV in sub-Saharan Africa who are over the age of 50, or about 14 percent of the population living with HIV in that region.

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