Day two focussed primarily on the issues of treatment and care, and responding to stigma. It has been especial privilege to have contributors from Kazakhstan, Ukraine, Belarus, Uganda and India, and the differences and commonalities between the experiences in these different nations in different regions of the world has been eye opening.
Treatment & Care in Resource Limited Situations
Dr Gisela Schneider spoke with great passion n the challenges of effectively treating people with late stage HIV infection. Quoting Colossian 3:17, she reminded us that caring for those living with HIV & AIDS is an act of worship to God.
The biggest challenge is that for all the work we have done in scaling up access to antiretroviral treatment [ART], the reality is that for every two people newly accessing ART, five are infected with HIV. We are not even running to stand still – and unless we scale up access to treatment dramatically over what has already been achieved, and start seriously investing in effective prevention, we are never going to get universal access. And it must be a combined strategy of treatment and prevention.
The reality is that effective treatment is not just about rolling out antiretroviral [ARV] drugs. Early diagnosis is key – so early testing is essential, which requires good voluntary testing and counselling. Good nutritional support is essential if ARVs are to be effective, along with effective diagnosis and treatment of opportunistic infections. We must have good palliative care, not just in terminal illness, but in controlling symptoms of opportunistic infections and managing the side effects of ART. Good psychosocial support is vital – community support, counselling and other forms of support to help the individual and their family deal with the pressures that are on them. You need well trained staff and volunteers to provide all of this support, as well as to deliver and monitor ART itself. Well trained clinical officers and nurses can deliver the majority of the care and treatment, you do not need lots of doctors, and this leads to a significant increase in capacity within health systems.
Once you have all of this, you are ready to start administering ARVs. First line treatment in most of Africa is usually with Nucleoside and Non-Nucleoside Reverse Transcriptase Inhibitors (in West Africa, where HIV2 is predominant, Protease Inhibitors are first line treatments). In Eastern Europe and Central Asia there was some debate over the best first line treatment.
In Africa the usual criteria to start ART was a CD4 count below 300 and a presenting Stage III AIDS defining illness. However, in practice, anyone with a presenting illness would go on to treatment, regardless of CD4 count.
While many thought ART would not work with poor, uneducated rural Africans, the evidence suggests that ART has reduced HIV related mortality by as much as 95% in rural Uganda, and other evidence suggests that compliance amongst Africans is significantly greater than among North Americans (85-99% in Africa versus 57-75% in the USA). Treatment support is vital – volunteer support in the form of treatment advocates are vital in reinforcing the message that compliance is like a marriage – you and your drugs are together for life!
Multi Drug Resistant TB (and more recently Extremely Drug Resistant TB) have become major problems for people living with HIV. But evidence suggests that much HIV infection is also being missed because people with TB are not being tested for HIV – the reality is that the two infections go hand in glove, especially in Africa and Asia.
Good monitoring and evaluation of treatment is essential – particularly early recognition of treatment failure. However, the big struggle is to get second line therapies – as most global funding is only for first line therapy. First line treatments can be as cheap as $92 per annum, but second line treatments are coming in at $600-1,200 per annum. There simply is not the funding for this, and it is becoming a major concern as more people are either being infected by resistant strains of HIV or are developing resistance after many years on ART.
The biggest future challenge is to start seeing people living with HIV and AIDS as part of the solution rather than the problem. They are the most effective educators, advocates and supporters and counsellors for the newly diagnosed. They are actors not passive recipients. The other major challenge is to start engaging heterosexual men in tackling the causes of gender based violence and the empowerment of women – if we are going to turn back the feminisation of the epidemic, we need the men to be part of the solution, not the problem. This is a key role that the churches can take on – re-educating men in their attitudes to sexuality and relationship with women from a truly Biblical basis.
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