A key theme at this year’s European AIDS Conference, currently being held in Belgrade, Serbia, is access to treatment and diagnostics. Though this sounds more like a developing than developed world problem, evidence presented at the conference over the last couple of days, by both clinicians and advocates, suggests that shortages in anti-retroviral medication (ARV) and diagnostic equipment to measure CD4 and viral load are as real here as in much poorer parts of the world.
In a survey presented this morning by Brian West of the European AIDS Treatment Group (EATG) – an organisation of robust treatment advocates and partners to this conference – data were gathered to establish ARV supplies and the impact on patient treatment when shortages occurred. Findings were startling, and in a number of countries, including Croatia, Turkey, the Russian Federation, and even France, there were a number of instances when a required ARV was unavailable, resulting in the need for a ‘switch’ or – worse – treatment interruption, sometimes for as long as 10 days.
Why does this occur? Many reasons were offered, coalescing around a two major themes. The first, poor budgetary planning, reflects in part the current global economic crisis, though is also often due to national governments simply not allocating enough funding – this is especially so in Ukraine for example. The second is more complex – weakened procurement processes. This can be due to mechanisms that are too infrequent (yearly events fail to reflect changes in context), corruption, being too decentralised (as in Romania), or because ministries of health are insensitive to the need for an ongoing and sustainable ARV supply (this applies to many countries).
These worrying findings were presented at a session focusing on how to ensure sustainable treatment for people living with HIV (PLHIV). Solutions were proposed, and according to a representative of the Ukrainian Network of People Living with HIV, Anna Koshikova, advocacy and community mobilisation was a remedy that achieved real success in Ukraine.
Like many other countries, Ukraine is transitioning from Global Fund support for ARVs to national government. As a result there are serious shortfalls in funding allocation which, together with bureaucratic delays and issues around quality control, has led to around 20,000 adult and 2,000 children facing the possibility of treatment interruption. This is not the first crisis – in January 2011, 330 patients were required to ‘switch’ their treatment due to drug shortages. For the community of PLHIV, this was simply untenable, and after a series of public demonstrations and campaigns – including one child writing to the Prime Minister asking him personally to buy medication for her mother - the government relented, and now promise full funding for ARV in 2012.
It is not only treatments that are in short supply however. A number of other presentations – both during this session and the opening ceremony – confirm that diagnostic equipment is also lacking. There are methods to evaluate clinically the health status of PLHIV (as recommended by the WHO), but in countries with a diverse and changing epidemic, early detection of changes in CD4 and viral load are required to ensure treatment is tailored and effective. Dr Gardena Drogovic Lukic, a senior clinician based in Belgrade, presented as illustration a study comparing two clinics - one in Serbia and one the UK – to demonstrate the implications. The findings show CD4 and viral load tests are carried out almost twice as often in the UK as Serbia. The local context is made more difficult because patients in Serbia tend to present at a much later stage (due to low uptake of HIV tests), and require more intensive monitoring. She also confirmed that mitochondrial toxicity (a side effect of certain ARVs) is rare in the UK, but in can be as high as in 20% of patients in Serbia.
David Haerry of the EATG closed this challenging session by highlighting a number of key points to consider when specific drugs may not be available, including: drug half life, and the risk of opportunistic infections in people with ‘nadir’ CD4 levels, who may require antibiotics and anti-fungal medication. He also pointed out that there is limited material on how to deal with drug shortages, and today the EATG released its own guidelines, Emergency guidance on ART forced treatment interruptions due to drug unavailability (forced stock-outs) for people living with HIV and their care providers in Europe and Central Asia. According to a press release accompanying the publication, ‘ARV treatment interruptions cause harm to the individual patient and to public health, increases the costs of treatment, and constitute a violation of the human rights of people living with HIV.”
This session, and others during the first two days of the conference suggest that though medical advances are clearly benefiting PLHIV, political and economic will is required to ensure treatment is actually available to those who need it.