Nathan Ford: Flying in the face of evidence
This blog entry was posted to the BBJ blogsite here.
Despite having its critics, most clinicians agree that evidence-based medicine is, on the whole, a good thing. But evidence is just one part of what drives policy, and this is nowhere more obvious than in the field of international assistance for HIV/AIDS.
Today (Dec 1) is World AIDS Day, and it is remarkable to think how much progress has been made in the past decade. Ten years ago, treatment for AIDS in Africa was considered unfeasible. Despite the huge mortality, donor policies were driven by a mixture of modelling studies that predicted that treatment was too expensive, and a less evidence-based opinion that treatment wouldn’t work in Africa because patients wouldn’t adhere to medications.
But with around 30 million people already infected with HIV/AIDS, it was clear that prevention alone would not be enough. The moral argument that every effort must be made to provide treatment pushed a global coalition of health providers, non-governmental organisations, academics, and people living with HIV/AIDS to advocate against patent barriers, and these efforts eventually forced the price of antiretroviral medicines down from US$10 000 per patient per year to a dollar a day. This achievement allowed small programmes to start, and fragments of evidence began to emerge showing that adherence and outcomes were as good as, and sometimes better than, those achieved in developed countries. Donors cautiously began to fund treatment, and treatment cohorts began to expand, enrolling hundreds, and then thousands of patients.
Today, more than 5 million people are receiving antiretroviral therapy. We have robust outcomes from most high-burden countries in terms of clinical, immunological, and virological outcomes. Randomised trials have tested the efficacy of diverse models of care, including home-based care and the delegating of clinical responsibilities from doctors to nurses. The broader benefits of antiretroviral therapy are being demonstrated – first through modelling, then through epidemiological analyses – in terms of population-level reductions in mortality, infectious and non-infectious morbidity, incident tuberculosis, and HIV transmission. Treatment costs have also dramatically dropped, with a decrease of over 99% since 2000.
Now, to the incredulity of everyone who has been dutifully monitoring and evaluating treatment in what must be one of the most accountable and successful global public health programmes ever to exist, donors are threatening to withdraw funding from HIV/AIDS. The same donors who ten years earlier cited lack of clinical or economic evidence are now, in the face of a wealth of robust evidence supporting efficacy and cost-effectiveness, claiming that AIDS is getting too much money, and that it’s time to do something else instead. The US government is turning its attention to maternal and child health, and several European countries seem to be turning away from health altogether.
With some 10 million people still waiting for antiretroviral therapy, the moral arguments in support of HIV/AIDS funding are as relevant today as they were a decade ago. Access to medicines is once again a growing concern, as the latest generation of antiretrovirals are, as ten years ago, priced out of Africa’s reach. Having assured patients they would receive treatment if they tested positive, as a means to encourage testing, we now risk having lied, abandoning them to their disease. The substantial gains made in the past decade will be lost without continued significant support. But if donors now turn their back on funding, they will be sending a message that should be of concern to the entire global health community—they will be saying that they value political whim over science and the health of those in the developing world. In fact, they will be saying they don’t care about evidence at all.
Nathan Ford has worked with Médecins Sans Frontières (MSF) since 1998, and is currently the medical coordinator for MSF’s International Campaign for Access to Essential Medicines.