Access to Antiretroviral Treatment
Antiretroviral treatment (ARV) treatment has proven very effective in helping those infected with the disease to maintain their health. In the earlier days of treatment, patients had to take numerous pills (sometimes as many as 20 a day) to try to maintain their health. The expense and burden of this was a barrier for many people. With ARV treatment, the drugs are often combined within one pill, thus greatly reducing the number of pills the patient needs to take on a daily basis. In 2013, French researchers announced 10% of those treated very early in the stages of infection (within 10 weeks) could be “functionally cured” after ARV treatment (Saez-Cirion et al., 2013). However, this was based on a sample of 14 people, so it should be viewed with extreme caution at this point.
Even South Africa is now aggressively promoting ARV medication. Initially these medications did not find favor with top South African officials. Instead, their minister of health promoted good nutrition as equivalent to ARV medication in fighting HIV (Nullis, 2005). But South Africa has now reversed course and has seen substantial progress. ARV medications are now promoted, and new HIV infection rates have been drastically reduced, including mother-to-child transmission (UNAIDS, 2012a). The South African government was able to negotiate a USD$250 million reduction in medication costs for ARV, a savings of almost 50%, which will allow them to treat many more people (“New ARV,” 2012).
Children require a special focus, as diagnosis and treatment present special barriers in young children. It is difficult to detect HIV early in children, especially in the Global South, because the mother’s antibodies are still in the child’s bloodstream, which may render blood test results incorrect in children. Thus, antibody tests are typically not used in infants, but rather another test (Avert, 2013a). However, diagnosis does not mean treatment. If untreated, the disease kills one-third of infected children before their first birthday and one-half before their second birthday (UNICEF, 2012c). Children’s access to ARV medication has been increasing markedly in recent years, although it still remains too low. In 2005, approximately 6% of children who need ARV medication were receiving it; by 2010, that figure had risen to 23%. Coverage varies markedly by region with access highest in the CEE/CIE countries and lowest in North Africa and Southwest Asia (UNICEF, 2012c).
Improvements have been made in children’s medications. Early pediatric medications had to be refrigerated, mixed with clean drinking water, or split from adult dosage pills (difficult to do accurately) (Doctors Without Borders, 2005). The cost of pediatric medications has dropped sharply; in 2009 it was about $50 a year for first-line medications compared to about $20,000 only a few years before (Avert, 2013a). Syrups are now available and granular sprinkles are being developed. The sprinkles are easier for babies to swallow and are easier to transport and store (“Better paediatric,” 2012). However, as noted, even with the recent rapid increase in access to medications, children do not have the same access to medications that adults do.
ARV medications were traditionally very expensive, but generic alternatives have been developed that are much cheaper. Brazil, India, Cuba, and Thailand have all developed generic medications for their own populations; India supplies 80% of the donor-funded medications to low- and middle-income countries (Avert, 2013b). Indian pharmaceutical companies helped lower the price for AIDS treatment from $15,000 per patient in the mid-1990s to about $200 in 2005, while also simplifying treatment by combining three medications into one pill, known as “triple therapy” (Avert, 2013b).
However, pharmaceutical companies argued that generic medications were reducing their profit and thus inhibiting them from recouping the money they spent on developing the drugs. In response, the Agreement on Trade Related Aspects of Intellectual Property Rights, known as TRIPS, was developed. After 2005, developing countries such as India and Thailand were not able to continue to develop generic drugs. They could continue to manufacture the older drugs, but not the newer medications, including second-line medications. Therefore, the most effective medications continue to be out of reach for poorer nations (Avert, 2013).
Almost all patients need to switch medications after a few years (due to reduced effectiveness) from more common “first-line” medications to stronger “second-line” medications, and eventually third-line medications. Generics have brought the cost of first-line treatment down to about USD$60 a year, but second-line treatment costs about USD$400 for the most affordable option—over three times as much (Medecins Sans Frontieres, 2011). In low-income countries, if people have to pay for their medication, many cannot afford it and will die. Even if funding is available through their government or international donors, the more expensive the medications, the fewer people who can be treated, again increasing the number of people who will die.
Several ways to deal with TRIPS have been developed. The patent holder can grant a “voluntary license” for manufacture, which has occurred in a number of instances. Second, a country can issue a “compulsory license” for drugs needed to fight a public health emergency without paying royalties to the patent holder. Several countries such as Brazil, Thailand, and Indonesia have chosen to do this; however, Thailand has received backlash in the world trade market as a result (Avert, 2013b; “Indonesia to override,” 2013). A “patent pool” has also been developed which holds the license to certain medications, thus easing and speeding the negotiations for generic equivalents (Avert, 2013b). The Least Developed Countries have been granted extensions to comply with TRIPS, most recently extended to 2021 (McClanahan, 2013).
The cost of the medications is not the only barrier. The medicines can have severe side effects due to their potency, especially for people who cannot afford food to help digest the medicine. Dr. Paul Farmer has pioneered an approach in Haiti called directly observed treatment (DOT). He employs village members to serve as accompagnateurs, who observe the patient taking the medicine at least once a day. This helps improve compliance with medication and offers the patient a local liaison if he or she is having difficulty with the side effects of the medication (Kidder, 2003) (see Box 6.1 for further information on Dr. Farmer and his work).
The use of local residents as health workers can be especially helpful in Africa as the medical infrastructure is lacking—another major barrier to treatment. Not only is there a lack of physical buildings and roads to transport medications, but trained medical personnel have been leaving their home countries for better working conditions and pay in the Global North, especially Britain. There is a shortage of almost a million health professionals on the continent. The ratio of health care workers per 1,000 population is 2.3 as compared to 24.8 in the Americas with the shortage particularly acute in the countries of sub-Saharan Africa (Naicker, Plange-Rhule, Tutt, & Eastwood, 2009).
Working with the local community to help devise solutions is extremely effective. For example, in Uganda, transportation costs and the distance to the health clinic to get medication every month was a large barrier to local residents being able to maintain their medication. Therefore, they determined each person would go every 3 months for his or her own check-up, and each month someone is nominated to collect medication for the other residents and bring it back to the village (“Basic health care,” 2009).
Additionally, providing widespread basic health care is vital for the population, including those with HIV. In Rwanda, universal health coverage has been developed; subscribers pay premiums together with a 10% co-pay, but preventative measures as well as treatment for HIV and others are completely covered. Based on a system of rewards for good health of its patients, Rwanda has seen a huge payoff in health outcomes, including an almost 80% decrease in AIDS-related mortality, the largest in the world (Farmer at al., 2013).