The challenge of simplifying and scaling up

MSF is in the process of adapting its approach to AIDS treatment to better fit the real-life conditions faced in developing countries. Our projects are using treatments with fewer pills, relying less on sophisticated laboratory tests, taking better advantage of the skills and resources of existing health care professionals such as clinical officers and nurses, and decentralizing the point of care to district hospitals and health posts.

MSF believes its experiences can offer some valuable lessons to countries' efforts to scale-up treatment. MSF also believes the primary responsibility for scaling-up needs to lie with national governments.

Latest Global Developments

During the past year, there have been several positive developments both at the national and international level:

  • The launch of the World Health Organization (WHO) 3x5 initiative (three million people on AIDS treatment by 2005) to mobilize international efforts to expand the number of HIV people on treatment;
  • The decision by the government of South Africa to establish a national treatment program;
  • The prices of ARVs have continued to fall: for example, the Clinton Foundation has negotiated a price reduction for some developing countries which nearly halves the lowest price to date to $132 per patient per year;
  • Money from the Global Fund to Fight AIDS, Tuberculosis and Malaria is beginning to reach endemic countries; and
  • Developing countries are beginning to put into practice the WTO "Doha Declaration" by actively stimulating competition between drug producers.

MSF's AIDS treatment experience

MSF has been caring for people living with HIV/AIDS in developing countries since the early 1990s, and the first MSF ARV treatment projects began in 2001. Approximately 9000 patients, including about 500 children, are currently on ARVs in 42 MSF projects in 19 countries worldwide.

The countries where MSF is treating patients with ARVs are: Burkina Faso, Burundi, Cambodia, Cameroon, China, DR Congo, Guatemala, Honduras, Indonesia, Kenya, Laos, Malawi, Mozambique, Myanmar, Rwanda, South Africa, Thailand, Uganda, and Ukraine.

These figures have increased rapidly over the past year - in July 2002, MSF was treating 1,500 patients in 10 countries. We expect the total number of patients treated to reach 25,000 in 25 countries by the end of 2004.

MSF does not offer ARV treatment in a vacuum, but instead aims to integrate treatment into a continuum of care: projects include prevention efforts (health education, prevention of mother-to-child transmission of HIV), voluntary counselling and testing, treatment and prevention of opportunistic infections, ARV treatment and nutritional and psychosocial support.


Clinical observations

MSF looked at clinical data for 10 of its larger projects which began during the period 2001-20032 and found that 87.6% of a total of 6,134 patients who initiated treatment were still on ARVs, while 9.9% died and 2.0% were lost to follow up or stopped treatment. In these 10 projects, MSF has observed that 70% of patients began treatment with an advanced HIV status (WHO stage 3 or 4).

Concerning the efficacy of first-line treatment, in eight of the 10 projects where data are available, first-line treatment failed in an average 0.7% of cases. In the seven countries where these data are available, patients showed an average CD4 cell gain of 145 after 12 months. In countries where viral load is available, such as South Africa, MSF observed that 87.7% of 146 patients studied presented with an undetectable viral load after six months.

These figures show good results. In nine out of the ten projects examined, a simplified first-line regimen - one pill twice a day - is used.

MSF and the new WHO AIDS treatment initiative

MSF welcomes WHO's willingness to provide global leadership in tackling AIDS. Its goal of getting three million people on treatment by the end of 2005 is highly ambitious. If the plan is properly funded and implemented, it will be a significant boost to countries' efforts to scale-up treatment.

Invited by WHO to put forward its experiences, MSF has shared the lessons it has learnt from its own treatment experiences and has urged WHO to facilitate the adaptation of treatment protocols to real-life conditions in high-prevalence countries.

There are two further issues which MSF believes need to be addressed by WHO:

Urgent need for research and development of new tools: It will not be possible to solely base scaling-up efforts on existing tools. New tools will have to be developed to respond to specific needs in high-prevalence countries. For example, at present, ARVs aren't well-suited for use by children, so for instance fixed-dose liquid formulations for infants and low-dosage or breakable fixed-dose combination tablets for children are needed.

The pharmaceutical industry is not going to spontaneously fill existing and future gaps such as easy-to-use first-line treatment for children, simplified second-line treatments and simplified diagnostic tools. The public sector, including WHO, should seek to define and lead the work on this research agenda.

Need to ensure that international HIV initiatives are politically and financially supported: Financing is still a problem. Since its inception in January 2002 the Global Fund to Fight AIDS, Tuberculosis and Malaria has received only US$4.7 billion in contributions from donor governments (for all three diseases), far less than the US$7-10 billion annually the United Nations has estimated is needed to fight AIDS.

1 Sources: UNAIDS and WHO, unpublished statistics, November 2003

2 The projects observed were Chiradzulu and Thyolo in Malawi, Uganda, Kenya, South Africa, two projects in Maputo in Mozambique, Cameroon, Cambodia, and Thailand.