Towards Universal Access: Scaling up priority HIV/AIDS interventions in the health sector

Last week the United Nations, UNAIDS, and WHO launched a new report focusing on access to treatment for people living with HIV/AIDS in low and middle income countries. The findings were mixed: although treatment in these countries increased 54 percent over 2005, coverage in general is patchy and inadequate. And the UN's stated goal of achieving universal access by 2010 is now only 3 years away.

Indeed, the numbers reflecting need are alarming. The report, appropriately named Towards Universal Access, shows that:

• last year only 11 percent of HIV-positive pregnant women were receiving treatment to prevent transmission to their children;
• only 15 percent of children in need of treatment had access to it;
• there are 5 million people in low- and middle- income countries who still need treatment.

The report pitches a few recommendations to overcome these statistics. Some examples:

• More attention to mothers and children;
• More attention injecting drug users, an emerging problem in Africa;
• Control of sexually transmitted diseases to prevent HIV transmission.

Toward Universal Access also lingered on the cost of drugs; the report comes at a time of heated debate between Abbott Laboratories and Thailand’s Ministry of Health. In early 2007, Thailand issued a compulsory license for Kaletra, prohibiting its patent. Abbott tried to assuage the government by offering Kaletra at a reduced price. When Thailand maintained its compulsory license, Abbott retaliated by offering a different version of the drug, Aluvia, to other developing countries at a reduced price. Just yesterday and after much criticism, Abbott changed its stance and agreed to offer Aluvia in Thailand at a reduced price, approximately $1000/person/year.

This concession has the potential to embolden other developing countries to take advantage of the compulsory license option of the TRIPS agreement and obtain second-line ARVs at a more affordable price.

As Toward Univeral Access states:

“With some exceptions in certain low-income countries the average prices paid for second-line regimens remain unaffordably high in low- and middle-income countries, where few or no prequalified generic alternatives are available.”

It further points out that access to second-line drugs in developing countries is completely disproportional to their financial abilities:

“…An average price of US$ 1600 per person per year is paid by South Africa for tenofovir + abacavir + lopinavir/ritonavir, whereas El Salvador pays US$ 7613 per person per year for the same regimen.”

The Abbott Laboratories/Thailand story was a small victory towards increasing access. But, as Lancet pointed out last week, it was achieved only after advocacy groups heavily pressured the WHO to be more aggressive with Abbott. Reliance on case-by-case advocacy efforts is not sufficient, either to convince pharmaceuticals to lower their prices or to empower governments to take advantage of their right to provide generic drugs.

To this end, Towards Universal Access issues a warning:

“Unless prices for second-line regimens fall significantly, countries will soon be confronted with budgetary constraints that may put treatment programmes at risk. It is vital to achieve further reductions in the prices of second-line drugs and to obtain more second-line generic alternatives.

Lancet offers a first step: "WHO can do more. Developing a robust plan on access to second-line drugs in collaboration with its partners...would be a good start. Such a move would show that WHO is serious about defending the interests of patients with HIV/AIDS."

World Bank: New Policies Backslide on Family Planning

Continued Support for Access to Contraceptives, Safe Abortion Crucial to Development

(New York, April 16, 2007) – By failing to explicitly support continued access to family planning and contraception, new World Bank policies, as drafted, would undermine a key strategy in the fight against global poverty, Human Rights Watch said in a letter to the bank’s board of directors.

“Women’s lack of control over their own fertility keeps millions of them mired in poverty,” said LaShawn R. Jefferson, women’s rights director at Human Rights Watch. “If the World Bank is serious about ending poverty, it needs to enhance women’s ability to make independent choices about having children.”

Traditionally, the World Bank has supported broad reproductive health programs as part of its population policy, but recent developments at the bank raise concerns about its continued support for this strategy. Last week, World Bank staff told reporters that the bank’s managing director, Juan José Daboub, ordered them to remove all references to family planning in a country package requested by Madagascar. Paul Wolfowitz, the president of the World Bank, subsequently denied that the bank was changing its policy on reproductive health, but did not affirm the bank’s support for access to contraception and comprehensive sex education.

A draft World Bank strategy paper on health and population leaked in early April recognizes that population growth is a significant challenge to developing countries’ ability to provide access to basic services. But unlike earlier documents, including the World Bank’s World Development Report of 2007, the draft fails to make explicit reference to the need for access to sex education and contraceptives. This omission would allow for the kind of measures taken on the Madagascar country package. The bank’s board of directors will reportedly review the strategy paper on April 17 and 18.

“The bank’s draft strategy paper fails to give people the key tools they need to participate actively and as equal partners in society,” said Joseph Amon, director of Human Rights Watch’s HIV/AIDS and human rights program. “This week, the World Bank’s board of directors must correct that omission.”

"Salud" the movie playing in New York on April 19th

WHO speaks out on health security on World Health Day

"Invest in health, build a safer future", the WHO said in a new publication honoring this World Health Day, April 7^th. In the face of rising temperatures and globalization, the international health organization looks to the increasing threats to health. The publication outlines its primary focus areas:

1. Emerging diseases;
2. Economic stability’s effect on mobility of people and goods, and consequently diseases;
3. Humanitarian emergencies, for example Hurricane Katrina;
4. Biological and chemical terror threats;
5. Climate change;
6. HIV/AIDS;
7. Building health security;
8. Strengthening health systems.

The WHO continued, saying, after the Security Council met to discuss HIV/AIDS in 2000, “public health was no longer seen as irrelevant to security or as its by-product; it had become its essential ingredient.”

The call was echoed by many around the world. Dattatreya Bant, a professor of community medicine at Karnataka Institute of Medical Sciences explained the specific links between health security and health to the Times of India: "They include sudden shocks to health and economies from emerging diseases, like SARS (severe acute respiratory syndrome) and avian influenza, humanitarian emergencies, bio-terrorism and other acute health risks."

Bant also commented on the challenges to health common across the world: "The shortage of safe drinking water and its impact on health and security after hurricane Katrina in USA, and the tsunami in Asia, clearly demonstrate the importance of advance preparation and the ability to respond quickly."

An editorial in The Rising Nepal commented, “As defined by the WHO, health is a state of complete physical, mental and social wellbeing, and not merely an absence of diseases or infirmity”. It went on to emphasize the commitment that is necessary to achieving this wellbeing:

“There are political and institutional obstacles to optimally utilizing these trained human resources in their actual field of interest and expertise…There is no doubt that an effective public health workforce is extremely important to improving the health system …It is increasingly realized that this requires a substantial commitment to a new and creative approach from all countries and donor agencies.”

“Shackles” or “budget allocations”?

On March 30, the Institute of Medicine released a report called, “PEPFAR Implementation: Progress and Promise” which evaluates the initiative’s progress over the last three years. The interpretations of this report have been as mixed as those of the controversial initiative itself:

The New York Times focused on the IOM’s assertion that the fight against AIDS is “hampered” by certain restrictions in the plan, in particular:

1. the requirement that 33 percent of all prevention money be spent on teaching abstinence (and nearly 60% of all money for the prevention of sexual transmission)
2. that the FDA must approve AIDS drugs already approved by the WHO
3. that the program cannot sponsor clean needle exchange programs using taxpayers’ money.
   The article stresses IOM’s call for a more sustainable approach and less emergency response, and ends with the critical fact that at the half-way point of PEPFAR, the program has not met its goals.

The Boston Globe also focused on the obstacles to the US effort to fight AIDS, citing the funding restrictions and the report’s call for greater emphasis on prevention.

The Washington Post took a more positive slant, referring heavily to the reports statements that the program has made a “strong head start” and PEPFAR’s success at treating pregnant women, but also cites the report’s call for less prescriptive budgeting.

So does the IOM’s report “please almost everyone” as the Washington Post says?

Mark Dybul, who oversees the implementation of PEPFAR, was thrilled, welcoming the report as “an endorsement of our program”. In response to the critique on the prevention programs he said “There is no abstinence-only provision. I wish people would stop calling it that. It’s abstinence until marriage.”

According to the New York Times Dybul also disagreed with the report that PEPFAR should pay for clean needle programs. “Needle exchange just continues the condition” Dr. Dybul said. This, of course, contradicts with the Institute of Medicine’s recent review of the effectiveness of needle exchange, and the endorsement of needle exchange programs by the AMA, APHA, the American Academy of Pediatrics and numerous other groups.

While many PEPFAR critics were glad the report highlighted a need for a less “cookie cutter” approach to HIV prevention, tailoring responses to the epidemiology and emphasizing evidence-based approaches, others felt the report pitted prevention against treatment. Gregg Gonsalves said “If one needed more evidence that the pendulum has swung away from access to treatment and back towards the pre-2000 conventional wisdom that poor people can't be and shouldn't be treated with ARVs, the New York Times article today on PEPFAR just confirms” it.

The news coverage also gave little coverage of one of the major findings of the report – that more attention must be paid to factors making women and girls more vulnerable to HIV infection, and that PEPFAR must invest greater in efforts to improve their legal, economic, educational and social status. "We are making the overall recommendation to find ways to empower girls and women and to protect them from sexual harassment and sexual violence," the panel's chairman, Jaime Sepulveda of the University of California at San Francisco, told reporters.

This recommendation led many activists to call for passage of the PATHWAY bill re-introduced by Congresswoman Barbara Lee (D-CA) and Congressman Christopher Shays (R-CT) on March 27. The bill would require all HIV prevention programs funded by the President’s Emergency Plan for AIDS Relief (PEPFAR) to address violence against women and would eliminate the earmark for abstinence-until-marriage programs (Read more).