Medical Director, Zanmi Lasante, Haiti; and Professor, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02155, USA
WHO's new Director-General has just declared AIDS to be a global health emergency. This move is not unprecedented but does signal a welcome departure from business as usual.
Can declarations change the world? They can if they lead to action commensurate with the problem. Two years ago, the UN convened a special session on AIDS. It produced plans to strengthen HIV prevention, reduce risk, and stave off death for those already infected by expanding access to treatment. Scientists and activists argued that, with adequate commitment, 3 million people in poor areas could be on antiretroviral (ARV) therapy by 2005 (1). But at our current pace, we are unlikely to have even a third of that number on therapy by 2005, and meanwhile transmission of HIV continues unabated. Each year millions are infected and millions die without ever knowing even mediocre services. To get from declarations to solutions, we must take three steps.
First, we have to acknowledge past failures. Our response to AIDS has so far been a failure. There has been scientific progress, but with few dividends for people living with poverty as well as HIV. In most of sub-Saharan Africa, they have access to neither prevention nor treatment. Three million deaths this year, and not yet counted millions of new infections, bespeak massive failure. The prevention-versus-care argument has been the most glaringly false of the debates impeding AIDS work in the most heavily burdened countries. In places like Haiti, we were told in addition to choose between treating tuberculosis and HIV. The lesson of the past decade is that such dilemmas are false.
Second, we should stop haggling over how best to allocate three dollars per capita on health care in the poorest countries, and explain to those who control the levers of finance that we cannot do good work with such paltry resources. It is fine to use cost-effectiveness analysis as a means of choosing interventions, but that is not what it has been used for. We see claims, for instance, published in leading medical journals, that HIV prevention is "28 times more effective than care." (2) How is it possible to attain such curiously specific numerical ratios when the cost of care is changing so rapidly? In our Haiti project, ARV prices dropped 90% during the year in which that claim was made (3). Meanwhile, those struggling to integrate prevention and care are dismayed by the steady decline in funds pledged for this scourge. Public health experts should explain to decision-makers that they have to allocate resources in proportion to the problem. The coming wave of mortality and epidemics worsened by HIV, including tuberculosis, will sooner or later force a change in policy, but we need to make it sooner rather than later.
Third, we should all press for integrated HIV prevention and care. The minimum package may start with redoubled prevention efforts, but will need to include prevention of mother-to-child transmission and improved care for the afflicted. We have learnt how to strengthen prevention efforts through a complex series of interventions that include destigmatization of AIDS through improved care. In central Haiti, where accompagnateurs see their sick neighbours every day and help them to adhere to therapy, we have documented a greater than 300% rise in demand for voluntary counselling and testing (VCT) each year since the introduction of ARVs. A simple fact is worth noting: as demand for VCT rises, the proportion of patients found to be uninfected will rise. This gives us the chance to do better at preventing new infections.
Improving AIDS care has also improved prenatal care and women's health, tuberculosis case detection and care, and the diagnosis and treatment of sexually transmitted diseases other than AIDS (4). Equally importantly, improved AIDS care has helped to strengthen long-neglected public health structures (5). In Haiti and in many countries in sub-Saharan Africa, there is a network of public clinics, but it is in disuse, as a result of calls for privatization, user fees and other "cost-recovery" measures.
Can anything good come from a declaration? Certainly, if it results in political will reflected by adequate funding for AIDS control. New directions for the future are already clear if we are willing to abandon failed policies. What must now happen is the integration of prevention and care, which amounts to the combination of sound public health practice and good clinical medicine. Slowing the AIDS pandemic requires nothing less.
1. Schwatlander B. Resource needs for HIV/ AIDS. Science 2001;292:2434-6
2. Marseille E, Hofmann PB, Kahn JG. HIV prevention before HAART in sub-Saharan Africa. Lancet 2002;359:1851-6.
3. Farmer P, Léandre F, Mukherjee J, Gupta R, Tarter L, Yong Kim J. Community-based treatment of advanced HIV disease: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy). Bulletin of the World Health Organization 2001;79:1145-51.
4. Smith Fawzi MC, Lambert W, Singler JM, Koenig SP, Léandre F, Névil P, et al. Prevalence and risk factors of STDs in rural Haiti: implications for policy and programming in resource-poor settings. International Journal of STD & AIDS 2003;14:1-6.
5. Mukherjee J. HIV-1 care in resource-poor settings: a view from Haiti. Lancet, 2003;62:994-5.