After Bangkok — Expanding the Global Response to AIDS
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《新英格兰医药杂志》
The progress that has been made in the global response to AIDS is real — but inadequate. An estimated 1 million people throughout the world are now using antiretroviral medications for human immunodeficiency virus (HIV) infection — double the number who were receiving such treatment two years ago. As of June 2004, 440,000 people from low- and middle-income countries were being treated.1 About 125,000 were from sub-Saharan Africa, where the burden is the greatest, an increase of 100,000 in two years. Spending on AIDS in low- and middle-income countries has increased from $1.0 billion in 2000 to $3.9 billion in 2002 and a projected $6.1 billion this year (see Figure). There are substantial funding mechanisms, such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria and, from the United States, the President's Emergency Plan for AIDS Relief. At the 15th International AIDS Conference, which was held in Bangkok, in July, Dr. Peter Piot, the executive director of the Joint United Nations Program on HIV/AIDS (UNAIDS), said that the worldwide response has entered a "new phase . . . finally, political, technical, and financial resources are starting to move." Yet in the past two years, 6 million people have died of AIDS, and 10 million have become infected with HIV.2 As Dr. Jim Yong Kim, director of the Department of HIV/AIDS at the World Health Organization (WHO), remarked, "All of us with the power and the responsibility to make a difference can only hang our heads in shame."
Figure. Estimated AIDS Spending and Projected Need in Low- and Middle-Income Countries.
Data are from the Joint United Nations Program on HIV/AIDS. Spending includes expenditures by governments (domestic and international) and by private organizations.
The International AIDS Conference has become a forum to focus public attention on the many aspects of the epidemic. It is no longer the cutting-edge scientific meeting that it once was. In Bangkok, prominent persons, such as Kofi Annan, Sonia Gandhi, actor Richard Gere, and Nelson Mandela had leading roles. The Bill and Melinda Gates Foundation announced $45.7 million in grants as well as a $50 million contribution to the Global Fund; the European Commission announced a $52 million contribution. Of the 17,000 delegates, about 2700 were registered as members of the news media. Of course, it was the development of diagnostic tests, effective drugs, and other medical advances that originally made the conference a global event. Before the next meeting, the organizers will have to decide how much to emphasize politics and money and how much to emphasize science and clinical care.
(Figure)
Figure. Demonstrators outside the 15th International AIDS Conference in Bangkok.
Courtesy of AFP/Getty Images.
The theme of this year's conference, "access for all," reflected the reality that advances against AIDS have primarily benefited people in wealthy nations. UNAIDS projects that in 2007, $20 billion will be needed for the global response (see Figure). This estimate includes the provision of antiretroviral medications to about 4 million people in sub-Saharan Africa and 2 million elsewhere, support for 22 million children who will have been orphaned by AIDS, and voluntary HIV counseling and testing for 100 million adults. These goals may not be achievable, either because governments will not provide the financial resources or because the logistics of organizing the care will be too formidable. Nonetheless, the very fact that such detailed estimates are being prepared suggests that there can be an effective and comprehensive response.
Both the medical and the social responses to AIDS are complex, involving education, prevention, counseling, testing, and a functioning health care infrastructure. In the realm of HIV prevention, there is debate about the relative importance of sexual abstinence, being faithful to one's partner, and the use of condoms, as well as about providing intravenous-drug users with clean needles, which the U.S. government opposes. Of perhaps 9 to 10 million injection-drug users in the world, needle and syringe exchange programs reach only about 150,000 and drug-substitution programs reach only about 20,000.3 Stopping AIDS, however, "is not a multiple-choice test: there is no one right answer to preventing the spread of this pandemic," as Ambassador Randall Tobias, the U.S. Global AIDS Coordinator, stated in a lecture.
Medical care requires the treatment of serious coinfections, such as tuberculosis (which is the leading cause of death in people with HIV), malaria, hepatitis, and sexually transmitted diseases. For example, many countries in sub-Saharan Africa do not meet the WHO's minimum standards for the number of physicians or nurses per 100,000 population. Shortages of health professionals are exacerbated when doctors and nurses leave for better positions and higher salaries in Western nations. In Asia, many nations, including China and India, have severe shortages of physicians who are trained to treat patients with AIDS. The problems of inadequate health care systems and inadequate numbers of trained personnel, which go well beyond the AIDS epidemic, threaten to undermine the progress that has been made. So do the stigma attached to HIV infection and discrimination against infected persons.
Although antiretroviral treatment is only one component of the responses to AIDS, it is as important as any other. Medications not only treat the infection, but also prevent many of the life-threatening complications of AIDS. Their availability provides a powerful incentive for people to be tested for infection and to receive counseling, which are central to both treatment and prevention efforts. According to Kim, "The opportunity to offer treatment to those denied access represents our best chance yet to accelerate prevention." Specific targets, such as the WHO's goal of providing antiretroviral medications to 3 million people in developing countries by the end of 2005 — the so-called 3-by-5 initiative — provide a clear measure of what has been accomplished and what remains to be done.
The WHO estimates the needs for antiretroviral therapy by calculating the number of people who are expected to die from AIDS within two years and adding 80 percent of the number currently receiving treatment.1 The most recent WHO estimates of the number receiving antiretroviral therapy reflect wide variations among developing nations (see Table). Brazil, which has an estimated 680,000 people living with HIV infection, and Thailand, which has an estimated 570,000, have high coverage rates. Of all the people in low- and middle-income countries who are receiving treatment, 142,000, or about one third, live in Brazil. In Thailand, more than 30,000 patients are being treated; the government's goal is 50,000. Brazil and Thailand have economic resources and are large producers of generic antiretroviral medicines, and can therefore aim for universal coverage. In sub-Saharan Africa, where many countries are far poorer and less stable, coverage rates range from 5 percent or less in South Africa, Nigeria, and six other nations where more than 1 million people are infected to 18.2 percent in Uganda and 30.0 percent in Botswana, home to 530,000 and 350,000 infected people, respectively (see Table).1
Table. Estimated HIV Prevalence and Need for Antiretroviral Therapy in Selected Low- and Middle-Income Countries.
Women now account for 47.7 percent of adults living with HIV infection or AIDS worldwide. In sub-Saharan Africa, they account for 56.1 percent.2 Each year, about 630,000 infants, including 550,000 in sub-Saharan Africa, contract HIV infection during pregnancy, labor and delivery, or breast-feeding. Eight percent of pregnant women in low- and middle-income countries are offered services to prevent mother-to-child transmission; some are not tested or decline to take medications. Only about 70,000 pregnant women with HIV infection — or about 3 percent of all such women — currently receive zidovudine or nevirapine to prevent mother-to-child transmission.3
In developing countries, the lowest prices for effective treatment with medications that meet international quality standards are for fixed-dose combinations of antiretroviral drugs (see page 739). Fixed-dose combinations cost less to produce than individual pills. They facilitate compliance and reduce the risk of drug resistance by allowing patients to take as few as two pills a day. In April 2004, the lowest prices for first-line treatment regimens ranged from $285 a year for generic single-pill combinations of stavudine, lamivudine, and nevirapine to $675 for a combination of zidovudine and lamivudine (GlaxoSmithKline) and nevirapine (Boehringer Ingelheim) taken separately.4 Although the combination of stavudine, lamivudine, and nevirapine is the most common first-line treatment in the world, many patients cannot take it because of side effects or because they need concomitant treatment for tuberculosis (nevirapine interacts with the antituberculosis drug rifampin). Experience in Uganda with the treatments that are actually used indicates that the average price for first-line treatment is $484 per year.4 The limited availability of pediatric formulations of HIV medications is an additional barrier to treatment, in Africa and Asia. Ninety percent of the 2.1 million children with HIV infection live in sub-Saharan Africa.2
According to the WHO, "substantial effort" and further cost reductions will be required to meet the December 2005 target of $50 to $200 per person per year.4 Achievement of this goal will probably require further decreases in the prices of brand-name medications as well as greater availability of fixed-dose combinations of brand-name or generic medications that meet international quality standards, such as those of the WHO or the Food and Drug Administration. There is also continuing concern about how international patent agreements and bilateral trade agreements that the United States is negotiating with Thailand and other nations will affect the availability of generic antiretroviral medications in developing nations.
By August 2006, when the 16th International AIDS Conference begins in Toronto, the outcome of the WHO's 3-by-5 initiative will be known. Unfortunately, the magnitude of the AIDS epidemic is such that even if the initiative succeeds, only about half the people in the world who are projected to need treatment will be receiving it. According to Piot of UNAIDS, access to treatment "means that increasing numbers of people will be on treatment for life, and that the more expensive second-generation therapies will need to be made accessible globally. So, while we must deal with the treatment emergency, it is imperative we plan for a sustained treatment effort." In the months ahead, there will be contentious battles over the financing and organization of the global response. There will also be tension between the need for broader availability of generic antiretroviral medications and the need for quality assurance in manufacturing generics, as well as many other controversies. But after years of waiting, a real start has been made toward controlling the great health care emergency of our time.
References
WHO HIV/AIDS Plan for January 2004-December 2005, investing in a comprehensive health sector response to HIV/AIDS. Geneva: World Health Organization, July 2004. (Accessed July 30, 2004, at http://www.who.int/3by5/en/HIV_AIDSplan.pdf.)
2004 Report on the global AIDS epidemic: 4th global report. Geneva: Joint United Nations Programme on HIV/AIDS, July 2004. (Accessed July 30, 2004, at http://www.unaids.org/bangkok2004/GAR2004_html/GAR2004_00_en.htm.)
US AID, UNAIDS, WHO, UNICEF, POLICY Project. Coverage of selected services for HIV/AIDS prevention, care and support in low and middle income countries in 2003. Washington, D.C.: Policy Project, June 2004. (Accessed July 30, 2004, at http://www.futuresgroup.com/WhatWeDo.cfm?page=Projects&ID=100.)
"3 by 5" Progress report, December 2003 through June 2004. Geneva: World Health Organization, July 2004. (Accessed July 30, 2004, at http://www.who.int/3by5/en/Progressreport.pdf.)(Robert Steinbrook, M.D.)
Figure. Estimated AIDS Spending and Projected Need in Low- and Middle-Income Countries.
Data are from the Joint United Nations Program on HIV/AIDS. Spending includes expenditures by governments (domestic and international) and by private organizations.
The International AIDS Conference has become a forum to focus public attention on the many aspects of the epidemic. It is no longer the cutting-edge scientific meeting that it once was. In Bangkok, prominent persons, such as Kofi Annan, Sonia Gandhi, actor Richard Gere, and Nelson Mandela had leading roles. The Bill and Melinda Gates Foundation announced $45.7 million in grants as well as a $50 million contribution to the Global Fund; the European Commission announced a $52 million contribution. Of the 17,000 delegates, about 2700 were registered as members of the news media. Of course, it was the development of diagnostic tests, effective drugs, and other medical advances that originally made the conference a global event. Before the next meeting, the organizers will have to decide how much to emphasize politics and money and how much to emphasize science and clinical care.
(Figure)
Figure. Demonstrators outside the 15th International AIDS Conference in Bangkok.
Courtesy of AFP/Getty Images.
The theme of this year's conference, "access for all," reflected the reality that advances against AIDS have primarily benefited people in wealthy nations. UNAIDS projects that in 2007, $20 billion will be needed for the global response (see Figure). This estimate includes the provision of antiretroviral medications to about 4 million people in sub-Saharan Africa and 2 million elsewhere, support for 22 million children who will have been orphaned by AIDS, and voluntary HIV counseling and testing for 100 million adults. These goals may not be achievable, either because governments will not provide the financial resources or because the logistics of organizing the care will be too formidable. Nonetheless, the very fact that such detailed estimates are being prepared suggests that there can be an effective and comprehensive response.
Both the medical and the social responses to AIDS are complex, involving education, prevention, counseling, testing, and a functioning health care infrastructure. In the realm of HIV prevention, there is debate about the relative importance of sexual abstinence, being faithful to one's partner, and the use of condoms, as well as about providing intravenous-drug users with clean needles, which the U.S. government opposes. Of perhaps 9 to 10 million injection-drug users in the world, needle and syringe exchange programs reach only about 150,000 and drug-substitution programs reach only about 20,000.3 Stopping AIDS, however, "is not a multiple-choice test: there is no one right answer to preventing the spread of this pandemic," as Ambassador Randall Tobias, the U.S. Global AIDS Coordinator, stated in a lecture.
Medical care requires the treatment of serious coinfections, such as tuberculosis (which is the leading cause of death in people with HIV), malaria, hepatitis, and sexually transmitted diseases. For example, many countries in sub-Saharan Africa do not meet the WHO's minimum standards for the number of physicians or nurses per 100,000 population. Shortages of health professionals are exacerbated when doctors and nurses leave for better positions and higher salaries in Western nations. In Asia, many nations, including China and India, have severe shortages of physicians who are trained to treat patients with AIDS. The problems of inadequate health care systems and inadequate numbers of trained personnel, which go well beyond the AIDS epidemic, threaten to undermine the progress that has been made. So do the stigma attached to HIV infection and discrimination against infected persons.
Although antiretroviral treatment is only one component of the responses to AIDS, it is as important as any other. Medications not only treat the infection, but also prevent many of the life-threatening complications of AIDS. Their availability provides a powerful incentive for people to be tested for infection and to receive counseling, which are central to both treatment and prevention efforts. According to Kim, "The opportunity to offer treatment to those denied access represents our best chance yet to accelerate prevention." Specific targets, such as the WHO's goal of providing antiretroviral medications to 3 million people in developing countries by the end of 2005 — the so-called 3-by-5 initiative — provide a clear measure of what has been accomplished and what remains to be done.
The WHO estimates the needs for antiretroviral therapy by calculating the number of people who are expected to die from AIDS within two years and adding 80 percent of the number currently receiving treatment.1 The most recent WHO estimates of the number receiving antiretroviral therapy reflect wide variations among developing nations (see Table). Brazil, which has an estimated 680,000 people living with HIV infection, and Thailand, which has an estimated 570,000, have high coverage rates. Of all the people in low- and middle-income countries who are receiving treatment, 142,000, or about one third, live in Brazil. In Thailand, more than 30,000 patients are being treated; the government's goal is 50,000. Brazil and Thailand have economic resources and are large producers of generic antiretroviral medicines, and can therefore aim for universal coverage. In sub-Saharan Africa, where many countries are far poorer and less stable, coverage rates range from 5 percent or less in South Africa, Nigeria, and six other nations where more than 1 million people are infected to 18.2 percent in Uganda and 30.0 percent in Botswana, home to 530,000 and 350,000 infected people, respectively (see Table).1
Table. Estimated HIV Prevalence and Need for Antiretroviral Therapy in Selected Low- and Middle-Income Countries.
Women now account for 47.7 percent of adults living with HIV infection or AIDS worldwide. In sub-Saharan Africa, they account for 56.1 percent.2 Each year, about 630,000 infants, including 550,000 in sub-Saharan Africa, contract HIV infection during pregnancy, labor and delivery, or breast-feeding. Eight percent of pregnant women in low- and middle-income countries are offered services to prevent mother-to-child transmission; some are not tested or decline to take medications. Only about 70,000 pregnant women with HIV infection — or about 3 percent of all such women — currently receive zidovudine or nevirapine to prevent mother-to-child transmission.3
In developing countries, the lowest prices for effective treatment with medications that meet international quality standards are for fixed-dose combinations of antiretroviral drugs (see page 739). Fixed-dose combinations cost less to produce than individual pills. They facilitate compliance and reduce the risk of drug resistance by allowing patients to take as few as two pills a day. In April 2004, the lowest prices for first-line treatment regimens ranged from $285 a year for generic single-pill combinations of stavudine, lamivudine, and nevirapine to $675 for a combination of zidovudine and lamivudine (GlaxoSmithKline) and nevirapine (Boehringer Ingelheim) taken separately.4 Although the combination of stavudine, lamivudine, and nevirapine is the most common first-line treatment in the world, many patients cannot take it because of side effects or because they need concomitant treatment for tuberculosis (nevirapine interacts with the antituberculosis drug rifampin). Experience in Uganda with the treatments that are actually used indicates that the average price for first-line treatment is $484 per year.4 The limited availability of pediatric formulations of HIV medications is an additional barrier to treatment, in Africa and Asia. Ninety percent of the 2.1 million children with HIV infection live in sub-Saharan Africa.2
According to the WHO, "substantial effort" and further cost reductions will be required to meet the December 2005 target of $50 to $200 per person per year.4 Achievement of this goal will probably require further decreases in the prices of brand-name medications as well as greater availability of fixed-dose combinations of brand-name or generic medications that meet international quality standards, such as those of the WHO or the Food and Drug Administration. There is also continuing concern about how international patent agreements and bilateral trade agreements that the United States is negotiating with Thailand and other nations will affect the availability of generic antiretroviral medications in developing nations.
By August 2006, when the 16th International AIDS Conference begins in Toronto, the outcome of the WHO's 3-by-5 initiative will be known. Unfortunately, the magnitude of the AIDS epidemic is such that even if the initiative succeeds, only about half the people in the world who are projected to need treatment will be receiving it. According to Piot of UNAIDS, access to treatment "means that increasing numbers of people will be on treatment for life, and that the more expensive second-generation therapies will need to be made accessible globally. So, while we must deal with the treatment emergency, it is imperative we plan for a sustained treatment effort." In the months ahead, there will be contentious battles over the financing and organization of the global response. There will also be tension between the need for broader availability of generic antiretroviral medications and the need for quality assurance in manufacturing generics, as well as many other controversies. But after years of waiting, a real start has been made toward controlling the great health care emergency of our time.
References
WHO HIV/AIDS Plan for January 2004-December 2005, investing in a comprehensive health sector response to HIV/AIDS. Geneva: World Health Organization, July 2004. (Accessed July 30, 2004, at http://www.who.int/3by5/en/HIV_AIDSplan.pdf.)
2004 Report on the global AIDS epidemic: 4th global report. Geneva: Joint United Nations Programme on HIV/AIDS, July 2004. (Accessed July 30, 2004, at http://www.unaids.org/bangkok2004/GAR2004_html/GAR2004_00_en.htm.)
US AID, UNAIDS, WHO, UNICEF, POLICY Project. Coverage of selected services for HIV/AIDS prevention, care and support in low and middle income countries in 2003. Washington, D.C.: Policy Project, June 2004. (Accessed July 30, 2004, at http://www.futuresgroup.com/WhatWeDo.cfm?page=Projects&ID=100.)
"3 by 5" Progress report, December 2003 through June 2004. Geneva: World Health Organization, July 2004. (Accessed July 30, 2004, at http://www.who.int/3by5/en/Progressreport.pdf.)(Robert Steinbrook, M.D.)