Chapter 002. Global Issues in Medicine (Part 5)

Chapter 182 provides an overview of the AIDS epidemic in the world today. Here we will limit ourselves to a discussion of AIDS in the developing world.Lessons learned in tackling AIDS in resource-constrained settings are highly relevant to discussions of other chronic diseases, includingnoncommunicable diseases, for which effective therapies have been developed. We highlight several of these lessons below.In the United States, the availability of highly active antiretroviral therapy (ART) for AIDS has transformed this disease from an inescapably fatal destruction of cell-mediated immunity into a manageable chronic illness.In developing countries, treatment has been offered more broadly only since...
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Chapter 002. Global Issues in Medicine (Part 5) Chapter 002. Global Issues in Medicine (Part 5) AIDS Chapter 182 provides an overview of the AIDS epidemic in the worldtoday. Here we will limit ourselves to a discussion of AIDS in the developingworld. Lessons learned in tackling AIDS in resource-constrained settings arehighly relevant to discussions of other chronic diseases, includingnoncommunicable diseases, for which effective therapies have been developed.We highlight several of these lessons below. In the United States, the availability of highly active antiretroviral therapy(ART) for AIDS has transformed this disease from an inescapably fataldestruction of cell-mediated immunity into a manageable chronic illness. In developing countries, treatment has been offered more broadly onlysince 2003, and only in the summer of 2006 did the number of patients receivingtreatment exceed 25% of the number who currently need it. (It remains to be seen how many of these fortunate few are receiving ARTregularly and with the requisite social support.) Before 2003, many argumentswere raised to justify not moving forward rapidly with ART programs for peopleliving with HIV/AIDS in resource-limited settings. The standard litany included the price of therapy compared to the povertyof the patient, the complexity of the intervention, the lack of infrastructure forlaboratory monitoring, and the lack of trained health care providers. Narrow cost-effectiveness arguments that created false dichotomies—prevention or treatment, rather than both—too often went unchallenged. Thegreatest obstacle at the time was the ambivalence, if not outright silence, ofpolitical leaders and experts in public health. The cumulative effect of these factors was to condemn to death tens ofmillions of poor people in developing countries who had become ill as a result ofHIV infection. The inequity between rich and poor countries in access to HIV treatmenthas rightly given rise to widespread moral indignation. In several middle-incomecountries, including Brazil, visionary programs have bridged the access gap. Other innovative projects pioneered by international nongovernmentalorganizations (NGOs) in diverse settings have clearly established that a verysimple approach to ART, based on intensive community engagement and support,can achieve remarkable results. In 2000, the United Nations Accelerating Access Initiative finally broughtthe research-based and generic pharmaceutical industries into play, and AIDS drugprices have since fallen significantly. At the same time, easier-to-administer fixed-dose combination drugs have become more widely available. Building on these lessons, the WHO advocated a public health approach tothe treatment of people with AIDS in resource-limited settings. This approach,which was derived from models of care pioneered by the NGO Partners In Healthand other groups, proposed standard first-line treatment regimens based on asimple five-drug formulary, with a more complex (and, up to now, moreexpensive) set of second-line options in reserve. Common clinical protocols were standardized, and intensive trainingpackages for health and community workers were developed and implemented inmany countries. These efforts were supported by unprecedented funding throughthe World Bank, the Global Fund, and PEPFAR. In 2003, the lack of access toART was declared a global public-health emergency by the WHO and UNAIDS,and the two agencies launched the 3 by 5 initiative, setting an ambitious target:having 3 million people in developing countries on treatment by the end of 2005. Many countries have since set corresponding national targets and haveworked to integrate ART into their national AIDS programs and health systemsand to harness the synergies between HIV/AIDS treatment and preventionactivities. The G8 (Gleneagles) 2005 communiqué endorsing universal access toHIV treatment by 2010 was another major step forward. It is clear by now that the claims made for the efficacy of ART are wellfounded: in the United States, such therapy has prolonged life by an estimated 13years per patient on average—a success rate that would compare favorably withthat of almost any treatment for cancer or for complications of coronary arterydisease. Further lessons with implications for policy and action have come fromefforts that are now under way in the developing world. During the past decade,through experiences in >50 countries thus far, the world has seen that ambitiouspolicy goals, adequate funding, and knowledge about implementation candramatically transform the prospects of people living with HIV inf ...