And the battle against AIDS continues
With the elusive search for AIDS cure and HIV infections hitting record high, even in developed countries, the poser as Nigeria joins the rest of the world to mark World AIDS Day (WAD) today, is how to win the battle against the dreaded Human Immuno-deficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS)?
By Chukwuma Muanya.
December 1, 2008, marks the 20th anniversary of the World AIDS Day (WAD). In 1988, the World Health Organization (WHO) declared the first WAD in an effort to raise public awareness about HIV/AIDS issues, including the need for support and understanding for people living with HIV/AIDS. The day is also an opportunity to highlight the need for continued development of education and prevention initiatives.
"Leadership" has been chosen by the World AIDS Campaign (WAC) as the theme for World AIDS Day 2007 and 2008. The WAC emphasis from 2005-2010 is that this theme will continue to be promoted with the slogan "Stop AIDS. Keep the Promise."
In Nigeria, the National Agency for the Control of AIDS (NACA) has adapted the theme with special focus on Counseling and Testing.
Towards universal access to care and treatment, experts are proposing mass testing plan, _scaling up priority HIV/AIDS interventions in the health sector and preventive use of drugs to tackle AIDS.
According to new findings based on a mathematical model developed by a group of HIV specialists in the World Health Organisation (WHO), universal and annual voluntary testing followed by immediate antiretroviral therapy treatment (irrespective of clinical stage or CD4 count) can reduce new HIV cases by 95 per cent within 10 years. CD4 is a marker for the immune system. The findings were published in The Lancet last week to stimulate discussion, debate and further research.
Authors of the study also report that the universal voluntary testing followed by immediate Anti Retroviral Therapy (ART) could have additional public health benefits, including reducing the incidence of tuberculosis and the transmission of HIV from mother to child. Additionally, the model suggests that there could be a significant reduction of HIV-related morbidity and mortality in resource-limited countries with generalized HIV epidemics.
The current WHO policy on treatment involves voluntary testing and clinical and/or immunological evaluation (example CD4 count) to determine eligibility for treatment with antiretrovirals (ARVs).
The authors emphasize the theoretical nature of the exercise based on data and raise a number of concerns regarding feasibility, including the protection of individual rights, drug resistance, toxicity and financing challenges.
As part of activities to mark the celebration of the 2008 WAD, NACA, in collaboration with all its partners will today embark on a one-week national HIV counselling and testing programme.
According to the Director General of NACA, Prof. Babatunde Osotimehin, the programme is aimed at reducing the prevalence of the disease through education. He said the day would begin with a rally, to be declared open by Vice President Goodluck Jonathan in Abuja with all states and local councils also having facilities to take part in the exercise.
While reiterating the benefits of the counselling and testing programme to mark the celebration, Osotimehin said that through counselling and testing, it would be easier for people to know their Human Immunodeficiency Virus (HIV) status, because according to him, "96 out of 100 people who test negative in a population will have more information about HIV and the prevention perspective is a major investment," which would help them reinforce their lifestyles so that they could live a HIV-free life.
He also said that for those who might test positive, they would have the advantage of early detection and go ahead to live their lives positively as many of them might not even need anti-retroviral treatment if they had not gone far in the disease because "it is about giving them good advice about their lifetime."
Other activities include the Federal Ministry of Education's interactive session which will involve school drama and arts competition, an avenue that will give the children an opportunity to talk and learn about HIV in order to arm them with enough information required to safeguard their future.
Also, Persons Living With HIV/AIDS in Nigeria (PLWHAN) are worried over their future. They decried the disparity and stigmatisation meted out to them at treatment centres and shortage of trained health workers attending to their needs. They also fear about the sustainability of the free treatment program in the wake of the global financial crunch.
Also, NACA has said the country may not be able to sustain its free AIDS drugs programme. According to the agency, the country must have an alternative plan to ensure that she continues to provide AIDS drugs to patients.
Former President Olusegun Obasanjo had in December 2006 announced free drugs for Persons Living With HIV/AIDS in Nigeria (PLWHAN).
Osotimehin told The Guardian: "I must also say there is something we should work well hard at now, and that is the issue of sustainability of the free AIDS treatment programme. United States (U.S.) is going through a crisis situation with the credit crunch and all of that. America pays for the President's Emergency Plan for AIDS Relief (PEPFAR) and I was listening to Joe Biden, the Democratic Party Vice President elect for U.S and of course there was an implication when they asked him, "if you guys win what are you going to do about the economy? Which of the sectors will suffer?"
"He mentioned foreign assistance. If that is correct, which it should be or could be. But you cannot be feeding people outside your territory while your people are hungry. If that is so, then we as a country must have plan B that we ensure that we will continue to provide service for our patients. I think it is something we need to work at."
It has been estimated that the Nigerian government is contributing around five per cent of the funds for the antiretroviral treatment programmes. The majority of the funding comes from development partners. The main donors are PEPFAR, the Global Fund and the World Bank.
PLWHAN are concerned that although they are better treated in the society today than what it used to be in the past, the long wait they are made to undergo before getting treatment at centres could cost them their jobs and cause more harm to the individual, the state, the health systems and the nation at large. They said though the AIDS drugs are free, the cost for medical examination, laboratory tests (X-rays) and treatment for opportunistic infections are not.
They wonder what is going to happen to them when International donor agencies withdraw their support for the country's AIDS treatment programme. The bulk of the money for the free AIDS drugs come from the United States President's Emergency Plan for AIDS Relief (PEPFAR), Global Funds for AIDS, the Global HIV/AIDS Initiative Nigeria (GHAIN) and other international partners.
The PLWHAN are also worried that if they miss their drugs for whatever reasons, the virus will become resistant to the drugs rendering them useless and the patient requiring a very costly second line of drugs to live.
Coordinator of NEPLWHAN, Mr. Ibrahim Umoru, said a situation- presently practiced in some secondary health facilities in the state- where HIV positive persons pay more for admission in a government hospital than HIV negative person is the peak of stigmatization.
Umoru said: For ARV and some contingents of opportunistic infection drugs, they are free. However there is a challenge somewhere; tuberculosis screening is not free at some sites here, X-rays is not free at some sites and this is a challenge. The major challenge we are now seeing is that our members spend a lot of time at treatment centres because of shortage of medical staff and risk losing their jobs."
A virologist at the Jos University Teaching Hospital (JUTH), Prof. John Idoko, told The Guardian that the challenges include "urgent need for rapid scale-up to all the country (urban and rural) of ART. Scaling up of Voluntary Counselling and Testing Centres (VCT) and community involvement." _
_Others, according to him, are strengthening labs to conduct CD4 counts (a measure of the body's immune system) and blood chemistry, monitoring and evacuation need for operational research to determine durability, resistance and other related issues. Urgent need for updating of the guidelines for treatment of opportunistic infections, taking care of children with HIV, geographical distribution of ART.
However, the Lancet's Africa AIDS study released last week indicated that the proposed global testing is woefully under-funded. There are also calls on global bodies such as the World Health Organization (WHO), Global Fund and PEPFAR to change course and direct more funding to HIV testing worldwide.
Indeed, the study published in the British medical journal last week, suggesting that testing all adults in Africa annually for HIV and immediately treating every person who tests positive could halt the AIDS epidemic in Africa within a decade, has spurred stakeholders to renew their call for the massive scale up of, and dramatically increased funding for global HIV testing and antiretroviral treatment worldwide.
Since 1981 when it was first observed that young gay men in Los Angeles, United States, were becoming ill as a result of what was later called Acquired Immune Deficiency Syndrome, or AIDS, scientists have made strenuous efforts to treat and prevent the disease.
By 1987 significant progress appeared to have been made, with the licensing of the first AIDS drug, AZT, and approval in the US for the first human trial of a vaccine. But it was not until 1995 that a new type of AIDS drug was approved, opening the way for the three-drug combination antiretroviral therapy (ART), which now keeps people with HIV well. Experts believed science would banish Aids, but all attempts to invent a vaccine have failed. One vaccine candidate, Aidsvax, completed large human trials in Thailand in 2003, but failed to protect against infection.
Prospects for a vaccine against HIV infection have slumped after a number of failures, particularly the halting last year of a trial by the pharmaceutical company Merck around which there had been great optimism. Microbicides - virus-killing gels that women could use before sex - have also failed to produce results. The biggest and best achievement in sub-Saharan Africa so far has been the roll-out of antiretroviral drugs, which are now keeping three million people alive.
The radical new strategy to stop the AIDS epidemic in its tracks proposed last week by WHO scientists, ran into immediate controversy over its implications for human rights.
The plan involves testing everybody for HIV every year in hard-hit areas like _sub-Saharan Africa and immediately putting those who are positive on AIDS drugs. It could slash dramatically the number of new infections, because AIDS drugs lower the levels of virus in the body, making HIV transmission through unprotected sex much less likely.
But the strategy raises major issues both over implementation and over ethics. Currently people who are HIV positive are not put on treatment until they need it, because of the toxicity and side effects of antiretroviral (ARV) drugs. It raises the prospect of subjecting people to potential medical harm for the public good, rather than their individual benefit.
The authors of the paper include Kevin de Cock, HIV/AIDS director at the WHO, who points out that this is a mathematical model for discussion, but says it offers hope at a time when other avenues appear to have closed. If this could be implemented in sub-Saharan Africa, he said, "the proportion of people with HIV would run to under one per cent in less than 50 years."
This year, Swiss experts published a consensus statement declaring that people with HIV on effective antiretroviral drugs for at least six months are not infectious. "The subject of antiretroviral therapy for HIV prevention and how best to use it has risen to the top of the scientific agenda, not least because of the discouraging results of vaccine and microbicide research," said De Cock.
Standard antiretroviral therapy (ART) consists of the use of at least three antiretroviral (ARV) drugs to maximally suppress the HIV virus and stop the progression of HIV disease. Huge reductions have been seen in rates of death and suffering when use is made of a potent ARV regimen.
About 33 million people are now living with HIV, of whom more than 30 million live in low- and middle-income countries and 15 million children have been orphaned. The 2005 HIV/AIDS sentinel survey in Nigeria indicated that about three million people are living with the virus. However, smaller surveys conducted last showed that the figures are dropping.
Recent statistics from UN and NACA show an apparent slow-down in the growth of the epidemic, and drugs to keep people alive are now at least partly available in heavily affected parts of the developing world.
De Cock pointed out the gravity of the situation in HIV-hit regions. In 2007, three million people were on drugs, but seven million were in imminent danger of dying if they did not get them soon. A further 23 million people were HIV positive and 2.7 million became infected last year. All will eventually need drugs to stay alive. The G8 promised universal access to treatment by 2010, but as the numbers expand, it will become ever harder and more costly to achieve.
"There is this major concern that the concept of universal access in the current scenario is not sustainable unless we manage to curb HIV transmission," he said.
The paper, whose lead author is Reuben Granich of the WHO's antiretroviral treatment and HIV care unit, says annual testing and immediate treatment "could greatly accelerate the transition from the present endemic phase, in which most adults living with HIV are not receiving ART (antiretroviral therapy), to an elimination phase, in which most are on ART, within five years". By 2016 there could be less than one death per 1,000 people a year.
Granich and colleagues say the strategy would need "a substantial, front-loaded investment", but that once transmission began to go down, the costs would be far less than current projections by the Joint United Nations Program on AIDS (UNAIDS) for universal access to prevention, care and treatment. By 2032, they estimate that the cost would equal that of current treatment and prevention efforts, at $1.7billion, but from then on it would drop.
In an accompanying editorial in the Lancet, Geoffrey Garnett and Rebecca Baggaley, of the department of infectious disease epidemiology at Imperial College London, say the strategy would be "extremely radical, with medical intervention for public health benefits rather than individual patients' benefits".
It "would reflect public health at its best and at its worst", they say. Treating people earlier could benefit them and protect their partners, but could also expose them to over-treatment and side effects. "Challenges will rightly come from those concerned about individuals' rights and patient autonomy, as well as from those who moralistically fear an 'easy' solution to HIV rather than behavioural change."
