MEXICO CITY — Despite ‘compelling evidence’ that people with HIV benefit when they start antiretroviral treatment earlier, widening access to treatment in countries with weak health systems may undermine the entire programme.
This was the warning sounded by renowned AIDS Cape Town-based activist Gregg Gonsalves to the International AIDS Conference plenary yesterday (thurs 7th).
Intense debate is raging both internationally and in South Africa about whether ARVs should be made available to people when their CD4 count (measure of immunity) drops to 350 rather than 200.
Studies show that patients’ immune systems recover quicker when they start ARVs with a CD4 count of 350 than wait until their immune system drops to 200, which is when South African patients can get ARVs.
But, said Gonsalves, while access to treatment at CD4 350 may be ‘clinically beneficial for individual patients’, admitting more patients in public health settings may weaken ARV programmes by ‘creating longer queues in already saturated national programmes using relatively temporary facilities, where even now the sickest patients still have trouble accessing medicines’.
‘Lifting the threshold for initiating ART to 350 cells without assessing the effectiveness and indeed the feasibility of this intervention at a population level in low and middle income countries may end up doing more harm than good,’ said Gonsalves, who heads the AIDS and Rights Alliance for Southern Africa (ARASA).
‘The question of when-to-start antiretroviral therapy has vexed the field for years now’it’s time to do a study to answer this question for resource-poor settings.’
Gonsalves also urged the AIDS conference to set firm global targets and deadlines to make sense out of ‘the definition of universal access [to ARVs which] is now irresponsibly vague’.
‘Unfortunately, the current campaign for universal access was built without global targets because UNAIDS and the US government refused to accept them,’ said Gonsalves.
‘Unless we have clear targets, with clear timelines, we will never reach our goal of universal access. Approximately 10 million people need antiretroviral therapy today. Perhaps we can’t reach that goal by the next time we gather in 2010 in Vienna, but let’s not leave Mexico City without attaching a firm deadline nonetheless. And let’s not set that goal so far in the future so it becomes essentially meaningless.’
He also urged everyone to stop talking about the shortage of healthcare workers and start empowering other people, including the patients themselves,
‘We can’t rely on a physician-driven model for providing antiretroviral therapy. There are simply too few doctors to go around. This means nurses, clinical officers, community health workers and even non-clinical staff need to take on activities they have never been asked or allowed to do, such as allowing nurses to prescribe ARVs.
But, said Gonsalves, the ‘greatest resource available is communities themselves’, and organisations needed to ‘enable patients, with the help of their families and communities to take more control of their own disease and its management’. ‘ health-e news service.