Here at the 19th International AIDS Conference in Washington (AIDS 2012), Médecins Sans Frontières (MSF) has released an important report tracking progress on access to anti-retroviral treatment (ART) in 23 countries.
Here at the 19th International AIDS Conference in Washington (AIDS 2012), Médecins Sans Frontières (MSF) has released an important report tracking progress on access to anti-retroviral treatment (ART) in 23 countries.Research on the policies, strategies and tools used to roll out ART suggests critical progress has been made in some countries. But in others access remains lamentably low, reflecting a policy gap around specific initiatives – such as task shifting – vital to ensure people living with HIV (PLHIV) receive the treatment they require.
Access to treatment has been central to the fight against HIV and the support of those affected since the late 1990s. Recent years have seen huge strides in rolling out access, and between 2006 and 2010 an extra 4.5m people began receiving ART. Currently, around 15 million people require treatment. Estimates suggest just over half (52%) can access it.
The MSF report Speed up scale up provides a vital resource for policy makers looking to increase access. It highlights issues around treatment access using 25 indicators – including the number of public sector facilities offering ART services, task shifting (to allow nurses to initiate ART or TB treatments), and whether national policies comply to protocols developed by the World Health Organisation (WHO).
The findings are illustrative, highlighting progress –and significant barriers – in the 23 countries. For example, in Swaziland, which has HIV prevalence of 26%, 80% of people requiring treatment have access. For Zambia, these figures are 14.6% prevalence and 77% access. In Ukraine, currently facing an increase in new infections rates faster than most African countries, HIV prevalence is 1%, but only 13.4% of PLHIV requiring treatment have access. Overall, 11 of the 23 countries surveyed have reached ART coverage of 60% or more; six are still reaching only one third of people in need. More worryingly, only 8 of the 20 countries with available data provide ART in 30% or more of their health facilities.
Speaking at the report’s launch, Sharonann Lynch, MSF’s HIV Policy Adviser, spoke of “two realities” – one in which countries continue to make progress in rolling out treatment, the other in which countries are slipping behind. “We’re at stagnation,” she said, referring to a decrease in the numbers of PLHIV starting treatment globally between 2010 and 2011.
Charles Sako, a Kenyan present at the launch who is living with HIV, said “justice delayed is justice denied”, a sentiment that brings home the fact that, although 54% PLHIV on treatment is a fantastic achievement, that 46% of people are still denied access is intolerable in this, the fourth decade of the HIV epidemic.
What factors can improve access? According to Tom Decroo, MSF Mozambique, “moving treatment down to the community level ensures that the interests of patients and health systems overlap.” Decroo argues for taking HIV care out of hospitals and moving it to a “model of patient care similar to that of chronic disease management in developed countries.”
A key component of this decentralising model of care includes task shifting, and it’s interesting to note that the country with the highest percentage of ART access – Botswana (96%) – allows nurses to initiate ART and TB treatments. Ukraine, with the lowest access (13.4%), does not. Whilst other factors no doubt contribute to Ukraine’s abysmal performance – for example, ART stock outs are not uncommon in Eastern Europe – its notoriously hierarchical health system does not encourage moving ART delivery out of a clinical setting.
Other issues, not just in Ukraine, also have significance such as pricing, national testing policies and government health expenditure. The release of Speed up Scale up comes at a crucial time, riding on a wave of hope that is so much part of this conference’s narrative so far.
If we are to achieve the goal of universal access to ART by 2015, as Lynch reminds us, we need to “double the rate of scale up,” year on year. This report highlights the key elements each country requires to meet this challenge.
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