DOI: 10.1097/01.aids.0000247110.51338.73

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PMID: 16988510

Issn Print: 0269-9370

Publication Date: 2006/10/03


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Durban 2000 to Toronto 2006: The evolving challenges in implementing AIDS treatment in Africa

Salim S Abdool Karim

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Excerpt

The Durban AIDS Conference in 2000 is a landmark in the global response to the AIDS pandemic. As the first International AIDS Conference held in Africa and the developing world, it created a unique juxtaposition between scientific advances, community aspiration, global inequity and stark reality of one of the worst affected areas in the world. With its inescapable political pressure, it ‘broke the silence’ resulting in the birth of a social movement with a common purpose and vision for affordable AIDS treatment [1]. The Durban AIDS Conference changed the discourse from ‘whether’ to ‘how’ to provide antiretroviral therapy (ART) in resource-constrained settings, especially Africa. On the eve of the Toronto AIDS conference, it is opportune to take stock of the challenges in AIDS treatment access, particularly in light of the significant resources made available by the Global Fund to fight AIDS, Tuberculosis and Malaria and the President's Emergency Plan for AIDS Relief.
Since the Durban AIDS Conference, the collective efforts of activists, researchers, service providers, pharmaceutical companies, policy makers and international agencies have generated real momentum in scaling up AIDS treatment and prevention across the globe, with special emphasis on Africa. Coverage of ART in the developing world has more than doubled – increasing from 400 000 in 2003 to approximately 1 million by June 2005 (Table 1) [2]. While still short of the WHO goal of ‘3 by 5’, the momentum in expanding treatment access is a remarkable achievement despite the initial challenges in implementing AIDS treatment programs, especially in Africa where the burden is largest, which included the costs of the drugs, concerns about adherence, and inadequate infrastructure for laboratory monitoring.
Affordability of ART, which was the rallying point at the Durban conference, is no longer a major stumbling block to treatment access. There have been drastic declines in the price of first line antiretroviral drugs for adults, e.g., in South Africa, Efavirenz, lamivudine (3TC) and Stavudine (d4T), three commonly used first line agents, cost $568 (R3411) per month in 2000 compared to the current price of $51 (R307) per month. At this price, it is comparable and often cheaper, than the cost of drugs for chronic diseases such as hypertension, asthma and diabetes. The costs of paediatric treatment as well as second and third line drug regimens have been coming down recently but are still relatively high. As demand for these increases, it is hoped that the larger volumes would also make these affordable.
It is widely accepted that good adherence to ART is fundamental to treatment success while inadequate adherence has a poor clinical prognosis and poses the public health hazard of drug resistance. The concerns about adherence in Africa, which emanated from pre-conceived notions about low education and literacy levels and knowledge of timekeeping, have been shown repeatedly to be unfounded by ART rollout programmes in the resource constrained settings such as Malawi [3], South Africa [4] and Uganda [5] which have all reported very high adherence levels. Importantly, the programmes have implemented innovative strategies to improve adherence including once-a-day regimens, minimizing the number of pills, avoidance of food precautions, fitting the antiretroviral drugs into the patient's lifestyle, and involvement of relatives, friends and/or community members in support of the patient's adherence [6].
A major advance in easing the burden of laboratory monitoring is the widespread availability of rapid HIV tests. Since specialized costly equipment is needed to perform CD4 cell count and viral load assays, these tests are not as readily available and remain expensive.
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