More cash, challenges in HIV fight

Nations viewed as unprepared to help patients

By John Donnelly, Globe Staff, 5/19/2003

ASHINGTON - President Bush is expected to sign into law as soon as this week the start of his historic $15 billion, five-year effort to fight AIDS. In the next few months, AIDS advocates will speak out loudly in favor of spending at least a third of that money in the next year, and giving $1 billion immediately to an international fund. 

The new reality in the fight against the killer pandemic is that once seemingly insurmountable financial barriers have fallen: Spending on HIV and AIDS globally has jumped from $300 million in 1999 to $3 billion last year, and soon will more than double again; and prices for lifesaving antiretroviral drugs have dropped by 85 percent in two years.

And yet, many world health experts are fretting. After AIDS advocates said for years that any time wasted meant sure death for those infected, the health specialists worry that they are not sure how to do the job.

''We do not know how to treat AIDS patients in Africa,'' said Richard Laing, a veteran global health specialist who will soon leave his job as associate professor of international health at Boston University for a position at the World Health Organization.

Laing and other health specialists said that the strides made by activists and Bush's professed determination to fight AIDS have obscured some big issues: Many countries in Africa, Asia, and the Caribbean are not prepared to handle huge infusions of money; many nations have only a fraction of the numbers of doctors, nurses, and other health workers needed to carry out new programs; and the dozens of small treatment projects haven't produced a set of basic guidelines that will tell health workers how to treat late-stage HIV and full-blown AIDS.

One main reason for the deficit of knowledge has been the lack of money for large-scale projects to treat people with AIDS in the developing world. But specialists also say a near-paralysis has seeped into the medical world, because for years there seemed no hope to obtain funding.

''What are the sort of things we don't know?'' Laing said. ''We don't know when to start patients on therapy, we don't know when to change therapy if it isn't working, we don't know how necessary is it to know a patient's CD4 count, or viral load'' - two indicators of how well a person's immune system can fight diseases.

Bush wants 2 million people treated with antiretrovirals in five years in 12 African countries as well as in Haiti and Guyana. The United Nations has set a separate goal of treating 3 million AIDS patients in the developing world by the end of 2005. But by the end of last year, only about 300,000 people were being treated in the developing world - two-thirds of them in Latin America and the Carribbean, and 50,000 in sub-Saharan Africa, which is the epicenter of the pandemic.

Several health officials said in interviews that the strategy now will be to build upon the small treatment projects and learn as they go.

''It's a bit like cancer therapy in the early years: You begin with certain treatments, monitor them, and make changes as you are treating,'' said Jonathan D. Quick, director of the WHO's Essential Drugs and Medicines Policy. He said a problem arises when broadening programs ''before you know as much as you want to know.''

Quick said a number of efforts are underway to coordinate activities and share information, including the formation of the International HIV Treatment Access Coalition, which encompasses governments, health organizations, nonprofit groups, and people living with AIDS. In addition, WHO's new leadership - the next director general, Dr. Jong-Wook Lee, is expected to be endorsed by the World Health Assembly in Geneva on Wednesday - plans as a top priority providing AIDS technical assistance to poor countries.

The HIV treatment coalition, in a report released last December, said that Brazil's national AIDS program could provide elements of a model for the developing world. Brazil's Ministry of Health estimates that its program, which treats more than 115,000 people, has averted 90,962 deaths between 1994 and 2002 because of treatment that includes antiretroviral drugs.

''Has anyone done this at this scale? The answer is yes - the Brazilian National AIDS program has, although their numbers are certainly much smaller than what is going to be faced in the most highly affected areas in Africa,'' said Nils Daulaire, president of the Global Health Council, a large coalition of international health groups. ''Moving from pilot programs to wide-scale implementation is the brass ring in this whole process.''

For many health specialists, the challenges are finding the right answers to innumerable details, in much more difficult situations than Brazil's. In sub-Saharan Africa, specialists estimate that 4.1 million people should receive antiretroviral drugs.

Laing, the BU health specialist, believes that the bulk of the HIV and AIDS money ought to be used to help strengthen health systems to ensure that proper treatment, care, and prevention of AIDS are put in place. If governments can't do the job, whether because of corruption, incompetence, or lack of funding, he said nongovernmental organizations should lead the rebuilding. This model already has begun with the Global Fund to Fight AIDS, Tuberculosis & Malaria.

''You need to invest in people, distribution systems, and in simple, standard treatment regimens,'' Laing said.

But Andrew M. Fullem, senior HIV/AIDS adviser for John Snow, a Boston-based public health consulting firm, said that public health workers can't afford to wait until systems are functioning fully or until all the treatment protocol has been worked out.

He recalled the early days in the mid-1980s of treating people with HIV or AIDS in the United States. ''Initially, you had a handful of cities where you could go to get health care,'' he said. ''Five years into it, we had doubled or tripled the numbers of facilities, and in 10 years, most small- to midsized cities had a doctor who could take care of HIV patients.

''You can't go to national programs immediately. You're not going to have a perfect system from the get-go,'' Fullem said. ''The days of talking about demonstration projects are over. Now we need to move with speed.''

John Donnelly can be reached at donnelly@globe.com.

This story ran on page A1 of the Boston Globe on 5/19/2003.
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