Here at the 19th International AIDS Conference in Washington, DC, Médecins Sans Frontières (MSF) released an important report tracking progress in implementing policies, strategies and tools to roll out coverage of anti-retroviral treatment (ART) in 23 countries. Results suggest there has been critical progress, but that in some countries, access to ART remains lamentably low, reflecting a paucity of policy around specific initiatives – such as task shifting – vital to ensure people living with HIV (PLHIV) receive the treatment they require.
Access to treatment has been central to the fight against HIV and the support of those affected since the late 1990s. Recent years have seen huge strides in rolling out access, and between 2006 and 2010 an extra 4.5m people began receiving ART. Currently, around 15m people require treatment, and estimates suggest 52% have access.
This report, ‘Speed up Scale up’ is important, and must provide a vital resource for policy makers. It highlights issues around treatment access using 25 indicators – including number of public sector facilities offering ART services, task shifting (so, if nurses are able to initiate ART or TB treatments), and compliance of national policies to protocols developed by the World Health Organisation (WHO).
The findings are illustrative, highlighting the progress – and significant barriers – in the 23 countries. For example, in Swaziland (HIV prevalence 26%), 80% of people requiring treatment have access. For Zambia, these figures are 14.6% (prevalence) and 77% (access). In Ukraine, currently facing an increase in new infections rates faster than most African countries, current HIV prevalence is 1%, but only 13.4% of PLHIV requiring treatment have access. Overall, 11 of the 23 countries surveyed have reached ART coverage of 60% or more; 6 are still reaching only one third of people in need. Perhaps more worryingly, only 8 of the 20 countries with available data provide ART in 30% or more of their health facilities.
Speaking during the release of this report, Sharonann Lynch, MSF’s HIV Policy Adviser, spoke of “two realities” – one, of countries continuing make progress in rolling out treatment, and two, those that are slipping behind. “We’re at stagnation,” she said, referring to a decrease in the numbers of PLHIV starting treatment globally between 2010 and 2011. Charles Sako, a Kenyan living with HIV said, “justice delayed is justice denied”, and this sentiment brings home the fact that, though 54% current treatment is a fantastic achievement, the 46% of people still denied access is intolerable in this fourth decade of the HIV epidemic.
What factors can improve access? According to Tom Decroo, MSF Mozambique, “moving treatment down to the community level ensures that the interests of patients and health systems overlap”, taking “HIV care out of hospitals” to move patient care to a “model of patient care similar to that of chronic disease management in developed countries.” A key component of this decentralising model of care includes task shifting, and it’s interesting to note that the country with the highest percentage of ART access – Botswana (96%) – allows nurses to initiate ART and TB treatments. Ukraine, with the lowest percentage (13.4%) does not. Whilst other factors also no doubt contribute to Ukraine’s abysmal performance – for example, ART stock outs are not uncommon in Eastern Europe – the notoriously hierarchical health system in that country does not encourage moving ART delivery out of the clinical setting.
Other issues - not just in Ukraine - are also significant, such as pricing, national testing policies, and government health expenditure. The release of ‘Speed up Scale up’ comes at a crucial time, riding on a wave crest of hope that is so much part of this conference’s narrative so far. If we are to achieve the goal of universal access to ART by 2015, as Sharonann Lynch reminds us, we need to “double the rate of scale up,” year on year. This report highlights the key elements each country requires to meet this challenge.