Challenges of AIDS treatment are no excuse: Treat Now

As a medical humanitarian organisation, MSF feels a responsibility not only to start people on ARVs but to ensure their lives are improved and prolonged over the longer term.

Like others, MSF was slow to start providing antiretrovirals to our patients in developing countries.

But we overcame our initial fears. In the Barcelona AIDS conference two years ago, we presented the encouraging data on the 1,000 patients that we had been treating thus far. Fred Minandi, one of the beneficiaries of our ARV programme in Malawi, spoke at the conference. He said: "I am one of the first patients to get ARVs for free in Malawi, and if I am here today able to speak with you it is because of this treatment."

Two years on, Fred Minandi is still doing well. He is one of the 13,000 people in 25 countries that MSF is now treating with ARVs - still a small number compared with the six million people who are in urgent need of ARVs in developing countries.

ARVs have transformed the lives of those receiving them, allowing them to work and have normal lives with their families. If they had not begun ARVs, we estimate that at least half of these 13,000 patients would have died within the year. According to data collected from MSF projects, the subset of patients who had been on treatment for at least 12 months had an 89% chance of survival.

MSF does not pretend to have come up with a model for providing AIDS treatment.

However, we have learned some important lessons about what it takes to scale up the numbers of people benefiting from ARVs. We have aggressively sought out the most affordable quality medicines for our patients and have begun simplifying and decentralising the way we deliver treatment.

Most of our patients now start on a three-drug fixed-dose combination -- one pill twice a day. We have also worked to decentralise care to the primary care level, simplify inclusion and follow-up protocols, reduce reliance on complex and costly monitoring tools, intensify training for health care staff and delegate more responsibility to nurses, clinical officers, and community health workers. In many countries, we work closely with networks of people living with HIV/AIDS and other community activists to enhance treatment education and promote adherence.

The encouraging clinical results of MSF's projects have helped make the case for scaling up. But we have also learned that there are immediate and emerging challenges that must be tackled.

As a medical humanitarian organisation, MSF feels a responsibility not only to start people on ARVs but to ensure their lives are improved and prolonged over the longer term.

This means being able to detect when a first-line treatment is failing and it is necessary to switch to second-line drugs. From published research we know that average failure rates are 30% at one year (as measured by viral load). However, it is difficult to diagnose early treatment failure because tools such as viral load and CD4 tests are rarely accessible and may not be practical in resource-poor settings.

There are very few alternatives if first-line therapy fails. The price of second-line treatment is one major barrier: second-line drugs currently cost five to ten times more than the first-line drugs because there is little generic competition. In addition, second-line drugs do not come in easy-to-use fixed-dose combinations.

Finally, entire patient groups such as children and pregnant women with HIV/AIDS have been neglected. For example, there are no appropriate formulations of paediatric antiretrovirals and no firm and clear guidelines on proper dosages for children.

This is why MSF is pursuing parallel tracks of action: we are putting as many people as possible on ARVs to prolong their lives, and we are fighting for more research into better drugs, monitoring tests and treatment strategies to keep them alive even longer. Other international and national initiatives need a similar dual focus.