SAN DIEGO, CA — In the old days, Joep Lange of the University of Amsterdam said, cost was more important than evidence.
Lange, a clinical researcher specializing in HIV therapy, and a past International AIDS Society president, was addressing the landscape of HIV treatment in countries with limited resources.
He followed with a review of the World Health Organization guidelines that relegated the D4t (stavudine) a low-priced but toxic HIV medicine to be phased out of treatment regimens and relegated to “back up status.” The good news — by 2012 most countries had followed the recommendation, and removed the medicine from their national guidelines. The bad news? in more than 40 percent of the countries, patients remain on D4t regimens.
Access to second-line treatment remains limited, risks that drugs used for pre-exposure prevention of HIV acquisition could conflict with treatment of those who do get HIV, need for new regimens — all are among the challenges that continue to dog treatment efforts. But, looking at challenges surrounding the medicines alone is a “myopic view,” he continued, if it distracts us from focusing on “the real challenges.”
Those challenges include sustainable financing for health care, inefficiencies in donor funding, the need to build national health budgets, and seizing the chances afforded by HIV testing, treatment and care to both build and simplify health care delivery.
“It would really be a missed opportunity,” Lange said, “if we test everyone and don’t take their blood pressure, or test their blood sugar.”
He was followed by Christopher Rowley of Harvard Medical School, who looked at advances in monitoring patients’ viral and immune cell counts, and how those, in turn, can advance the effectiveness of treatment on individual and population levels.
If only a patient’s immune cell count is monitored (currently as far as routine monitoring goes in resource-limited settings fortunate enough to have the ability to do that much) the failure of treatment will be noticed only after the virus has had a chance to replicate, endangering the patient’s health, and making the patient likelier to transmit the virus. The costs of testing equipment has put them out of reach of health care settings where they are needed most, though. Less expensive ones have been devised (one, unfortunately was discovered to be overestimating patient’s immune cell counts, keeping them ineligible for treatment when treatment was, in fact, needed) but other challenges have included inadequate technical support and training to keep the machines running.
Still, the stakes for developing capacities to monitor patients correctly where they come for care have been demonstrated, with one study showing that with answers available on the spot the number of patients lost to follow up care dropped from 57 to 21 percent.
More of the challenges and solutions to getting and keeping patients in care was the substance of the last talk, by Ingrid Bassett of Harvard Medical School.
Finding infections early and late have their own challenges. A typical patient beginning antiretroviral treatment arrives very sick — too sick, sometimes to become an active participant in their care. People diagnosed with HIV — but not yet eligible for antiretroviral treatment by current standards — who in showing up healthy “have done what we wanted,” as Bassett put it, fall through the chasms that make getting health care in general a challenge in resource limited places, and relatively few show up to be retested.
Of people starting treatment, the stigma of regular visits to an HIV clinic, the transportation costs, user fees — and improved health — all contributed to dropping out.
Patient tracers, transportation vouchers, eliminating fees, and a much heralded co-operative style group of patients in Mozambique who take turns traveling to the nearest clinic to pick up members’ medicines, were among the home-grown and low-cost answers to treatment default and failure. Bassett also pointed to proactive steps of providing more services at visits, incentive pay for return visits and adjusting scheduling for shorter wait times.