HIV/AIDS: global trends, global funds and delivery bottlenecks

Despite increased resources being available to address the global AIDS challenge, the infection continues to spread. Table 1 shows the regional progression in HIV infection rates over the last five years.

HIV prevalence is intensifying in most regions, with sub-Saharan Africa, Eastern Europe and Central Asia being the worst hit, accounting for approximately 79% of new infections between 1998 and 2003. Although the greatest number of people living with HIV are in sub-Saharan Africa, of equal concern is the growing epidemic in Central Asia [3].

The epidemiology of the disease differs between regions. It has been suggested that, due to dissimilar patterns of sexual behaviour between Africa and Asia, the extent of the spread to the heterosexual population in Asia will be circumscribed. In most of sub-Saharan Africa, HIV spreads through an intricate web of relationships from sex workers to male clients to female spouses/partners. According to Peter Piot of UNAIDS, females in Africa generally report more sexual partners than their Asian counterparts [4]. In most of Central Asia transmission is virtually linear, from intravenous drug users to sex workers to male clients to female spouses/partners, with women tending to monogamy [4]. The next decade will attest to the accuracy or error of this prediction. Rising prevalence is, however, not confined to developing countries, as an increase in the number of HIV infections is evident in all other regions except South and South East Asia (where inconsistencies in data collection methods have tended to skew the figures).

Table 2 shows in summary the demographic impacts of the epidemic, while Table 3 shows the impacts on various other aspects of society. The ramifications of an epidemic of this nature and scale will be felt long after incidence of the disease has peaked, predicted in the case of HIV to be in 2040 [12]. By way of comparison, the consequences of the Black Death (1347 – 1351) extended far beyond the life of the epidemic itself, exerting influence for about 150 years in Europe [13]. In order to mitigate these effects, massive investments in prevention, treatment and care programmes and in broad development initiatives must be given priority.

Various global initiatives and collaborations are addressing the global HIV/AIDS challenge. For example, the United Nations Millennium Development Declaration, signed in 2000 by 189 nations, encompasses eight Millennium Development Goals (MDGs), three of which are health related: reducing child mortality, improving maternal health, and combating HIV/AIDS, malaria and other diseases, by 2015 [14]. Many international organizations have been set up to assist in funding and implementing HIV prevention and care programmes and related health initiatives worldwide. These include the President's Emergency Plan For AIDS Relief (PEPFAR); the Global Fund to fight AIDS, Tuberculosis and Malaria; RollBack Malaria, the Global Alliance for Vaccines and Immunization; the Global Health Council; Médecins sans Frontiers; the Bill and Melinda Gates Foundation; the World Bank Multi Country HIV/AIDS Programme (MAP); the Accelerating Access Initiative and the William J. Clinton Presidential Foundation. These organizations contribute increasing amounts of money to confront AIDS and other pressing global health issues. UNAIDS [8] reports that in 1996, approximately US$330 million was available for HIV/AIDS initiatives worldwide, a figure which had risen to US$4.7 billion by 2003. Although this represents a huge increase in funding, it is still less than half the amount of US$12 billion that is now required, and this exigency is expected to rise to US$20 billion by 2007.

Despite the large amount of aid being made available in addressing the AIDS epidemic, shortfalls in both money and numbers of people being reached are apparent. Of the estimated 6 million people in developing countries who are in need of ART, only 400,000 currently receive it. Of these, 208,000 are in Brazil alone [15]. Even if the World Health Organization's '3 by 5' effort, which aims to provide treatment to 3 million people by the end of 2005, is successful, it will have addressed only 50% of the demand for treatment at the current level of need. The MDGs are unlikely to be met at the current rates of progress, with the worst affected countries likely to make the least headway.

Another issue of concern is that the focus of many of these programmes is on treatment rather than prevention of HIV. Initiatives geared to increasing the delivery of treatment to developing countries has increased substantially since 2001, when the Declaration of Commitment on HIV/AIDS was signed by 189 member states of the United Nations [16]. For example:

Current data suggests that approximately 33% of funding for AIDS initiativesbe allocated for treatment and care, with approximately 51% for prevention programmes [19]. Schwartländer et al [20] advocate a similar split in fund allocation between treatment and care on the one hand, and prevention initiatives on the other.

During the early stages of the epidemic, programmes designed to prevent HIV had rightly been the prime endeavour of poorer countries; indeed there was little else on offer. Even when the prospects of effective specific antiretroviral treatment improved after 1996, many scientists and health professionals remained committed to a dominant role of prevention over treatment and care. Prevention services, they believed, were not restricted to prophylaxis but included palliative care and the management of opportunistic infections. The latter were inexpensive and cost-effective; the concern was that highly active antiretroviral therapy (HAART), being more costly, would drain money from prevention programmes. But the direct and indirect financial, social, economic, political and security costs of failing to introduce effective prevention measures are undeniably very high. Based on figures from previous studies [21], Marseille et al modelled the cost-effectiveness of HAART against cotrimoxazole prophylaxis, and found that the ratio between the cost-effectiveness of HAART and prevention is US$350:US$12.50. (a ratio of 28:1). In human terms, for every life-year gained through HAART, 28 life-years could have been gained through prevention [22].

Marseille's evaluation, however, disregards the synergy between prevention and treatment interventions. Prevention, although an important component in addressing the epidemic, is inadequate in isolation. The low rates of uptake of preventive measures in many developing countries, which we discuss later, do not diminish this assertion. In addition to prevention programmes, the provision of HAART is not only financially feasible, but morally imperative. The difficulties associated with introducing ART are well known: there is no eradication of the virus, therefore treatment is lifelong; adherence lapses occur; drug formulations are not optimised; drug toxicities are frequent; drug-drug interactions complicate management and drug resistance requires special attention. In addition, there are aspects of HAART management which are still not settled – optimal start time and regimen sequence, the meaning of regime failure, and the sustainable reduction of resistance. The World Health Organization argues that the provision of ART, through its ability to prolong life and alleviate fears about HIV, can both change attitudes to the disease and, in combination with prevention, greatly reduce HIV transmission. It is suggested that resource-constrained countries such as Senegal, Thailand and Brazil, which introduced HAART early, are also the countries with the greatest success in controlling the epidemic. A 70% decline in AIDS-related deaths in affluent countries, where ART is available to the majority of the population, is cited to support this assertion [15].

It is becoming apparent that the advantages of ART might be offset by factors which may, on balance, fail to prevent or reduce transmission of the virus. These include disinhibition of risky sexual behaviour, the spread of drug-resistant strains, and an increased risk of exposure to HIV due to the improved survival rates of infected persons. In the context of the developing world, these putative negative impacts are likely exacerbated for several reasons:

Despite these inherent hazards, given the continued escalation in HIV infections worldwide, it is reasonable and compassionate to attempt to achieve synergies between HAART and prevention services through their simultaneous implementation.

UNAIDS has identified a comprehensive list of prevention, treatment and care services which define standard services for HIV/AIDS control (Table 4). Most of these interventions are affordable by poor countries, either through their own budgets or from donor funds. A key issue is incorporation of applicable interventions into existing health services and programmes.

An over-reliance on donor funds can reduce the long-term sustainability of aid programmes, and the reduced absorptive capacity of recipient countries for such assistance often results in bottlenecks, preventing aid packages from being used where they are most needed. As a result, despite higher levels of acceptance of AIDS by certain governments, a global climate of increased political stability and economic growth, and greater public access to information and advocacy, inequitable access to treatment and prevention persists. While challenges experienced by households and communities in terms of providing resources for home-based care are also significant hindrances to the effective delivery of care, shortcomings inherent in health systems constitute the major blocks in channeling ever-increasing amounts of aid to those most in need. It follows that inequities in the provision of healthcare services may escalate in the coming years unless efficiency is coupled with justice in the construction of national health systems.

Constraints relating to supply within health systems, including finance, information systems, human resources, drugs and logistics [14], as well as those on the demand-side, such as increased patient numbers, and stigma and discrimination among communities [8], hinder progress.

The example of introducing prevention of mother to child transmission (PMTCT) programmes, which are among the simplest and most cost-effective of anti-HIV programmes available, into national health systems, is illustrative of the challenges faced by developing countries. Single dose Nevirapine (a dose each to mother during delivery and to her newborn) is the most widely used regimen for PMTCT, having the advantages of simplicity, affordability, and effectiveness. Most programmes and agencies, including UNICEF, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), and state authorities, have found that in developing countries, of the women who should be given ART, only a minority receive the drugs. Even fewer infants are given their prophylactic dose of Nevirapine. Until recently, experience suggested that, despite wide variations between countries, in general, of the HIV positive women attending antenatal clinics, probably < 20% received ARVs. Neff Walker [24] has estimated that, of the 2.1 million pregnant women who are HIV positive in any given year globally (excluding high-income countries), only 200,000 receive PMTCT interventions.

Current information from some centres, however, suggests that uptake is improving. Data from studies undertaken in Kwazulu Natal, South Africa – a region severely affected by the epidemic – show that, for 150,000 deliveries per annum, PMTCT coverage increased from 10% in 2001 to 78% in 2003/04 (Figure 1) [25]. Reasons for such improvements in a number of countries may be attributed to:

Figure 2, taken from the same study, shows that despite this increase, only 59% of women attending antenatal clinics who test HIV-positive actually receive Nevirapine. Much of this attrition is due to failing health systems, although other factors, such as stigma and discrimination, also have an effect on poor uptake.

The World Health Report (2004) states that "The 3 by 5 initiative...cannot be implemented in isolation from a regeneration of health systems." [26]. Several studies support this statement, reflecting the unfavourable conditions in the health care systems of developing regions [27, 28].

UNAIDS [8] suggests that, in order to build capacity, an approach which incorporates training, technical assistance and access to improved guidelines and tools should be adopted by funders. In order to utilize resources effectively recipient countries need to undertake thorough planning processes whereby goals relevant to that country are set and allocation of funds is made according to need [29, 30].

However, constraints may have multiple causes, both within and external to the health system itself, which may themselves be interdependent. Two approaches to overcoming constraints may be identified: dealing with constraints specific to the disease across all aspects of the health system, or addressing specific weaknesses in the health system across all diseases. It has been argued that disease-specific programmes can build skills and develop effective management structures to allow health services to cope with the demands placed on them [31]. The scale and nature of the HIV epidemic is such that it is generally the most pressing health challenge faced by developing countries. As such, an approach specific to the disease itself could be seen as the most effective way of building the capacity of health systems in countries of need, as it may be a more manageable way to address weaknesses in the health system while at the same time delivering short-term returns. This approach can, however, result in parallel systems being set up, and can cause disruptions in day to day healthcare provision. There are multiple overlaps in the health service requirements for HIV/AIDS and those for other diseases, which constitute a compelling argument to avoid as far as possible vertical schemes for HIV prevention and treatment interventions. For example, PMTCT programmes cannot be isolated from adequate antenatal clinic services, family planning, delivery facilities, and ambulatory services for chronic diseases of women and children. Indeed, the inclusion of male partners as an essential component in PMTCT-Plus indicates the broad sweep of interconnected services necessary. The frequent coinfections between HIV and tuberculosis are persuasive reasons for seeking complementarity between services for each. A system-wide response has the advantage that constraints addressed benefit a range of diseases, and draws attention to other health challenges that may be overlooked in the context of HIV/AIDS. Although the results of this approach may not be as quickly seen as in the disease-specific approach, it allows the system in its entirety to be strengthened.

It follows that the health system, rather than the specific disease, should be tackled in order to achieve the effective and holistic delivery of interventions. Such restructuring tends to be effective only in the long term, so immediate interventions may have to be introduced into the health system to deal with the pressing needs of prevention and of HIV/AIDS patients.

Robust health systems play a fundamental role in channelling globally recognised prevention and treatment best practice for the mitigation of HIV/AIDS. However, certain social and biological complexities profoundly affect the transmission, progression and mortality of the disease; these lie beyond the scope of health services. Intrinsically difficult to control, these elements constitute significant obstacles to the prevention and management of the HIV/AIDS epidemic. Biological factors, such as exposure to infected individuals (through sex, contaminated blood products, or perinatally), infectivity (determined by the viral load), and concomitant sexually transmitted infections (STIs) greatly increase susceptibility to infection. Social and environmental determinants, which include socio-economic status (for example, unemployment, poverty, degree of urbanisation and migration) may increase proclivity to risky behaviour (such as unprotected sex or drug use) and heighten the possibility of infection. Another important factor here is gender and age: women's lower status and adolescents' relative youth renders both groups more vulnerable to infection due in part to a consequent lack of power in relationships. [32‐38].

It follows therefore that addressing health system constraints alone will not constitute a comprehensive solution to the management of the epidemic. Mitigation of risk factors needs to be an integral part of the response to HIV/AIDS in order for real progress to be made in the propitiation of the disease.