Early success highlights need for more progress

Many of the 500,000 African babies born infected with HIV each year won’t live past age 2, a fact made even more appalling by the fact that doctors know how to halt mother-to-child HIV transmission.

That sobering figure was just a part of the mixed picture about AIDS in Africa painted during an afternoon symposium at Harvard Medical School’s New Research Building on Nov. 19. Speakers at the event, “AIDS in Africa: Long-Term Effects of ARV Therapy,” hailed the progress made on the continent since a key conference in Durban, South Africa, in 2000, but described a still-dismal picture of an epidemic that has the upper hand despite major advances in the industrialized world.

The event’s two keynote speakers, Deborah Cotton, chief medical officer of the Clinton Foundation HIV/AIDS Initiative, and Jean Paul Moatti, professor of economics at the University of the Mediterranean and an adviser to the director-general of the World Health Organization and to the executive director of the Global Fund Against AIDS, Tuberculosis and Malaria, both decried the continued transmission of HIV from infected mothers to their babies. Moatti said the number “disgusts” him, while Cotton questioned why any children are born with HIV infections at a time when medical knowledge knows how to prevent transmission.

The event, which brought several hundred interested students, faculty, and experts in the field to the Joseph B. Martin Conference Center, was sponsored by the Harvard Initiative for Global Health, the Harvard School of Public Health (HSPH) AIDS Initiative, the Harvard University Center for AIDS Research, and the HSPH Department of Immunology and Infectious Diseases.

The event was introduced by Dyann Wirth, Strong Professor of Infectious Disease and chair of HSPH’s Department of Immunology and Infectious Diseases, and by Max Essex, Lasker Professor of Health Sciences and the head of the HSPH’s AIDS Initiative. It featured presentations by several Harvard faculty members working on the problem of AIDS in Africa as well as professionals working in the field on the problem.

Essex said that ARV, or antiretroviral drug therapy, in marked contrast to vaccine efforts, has been particularly successful where it has been implemented. In places where ARV therapy has been rolled out it has been successful at increasing life span, and patients seemingly understand the stakes of adhering to their drug regime — and they’ve proven motivated, coming long distances to get care.

Essex said effective vaccines against HIV remain 10 to 15 years away, so the battle against the virus will focus on improving prevention and treatment. Essex said that future efforts to wield ARVs against HIV may stress early intervention with ARV drugs as a way to not only keep the patient healthy, but also to lower transmission rates.

In her keynote speech, Cotton said that before the Durban conference in 2000, stereotypes held back ARV therapy in Africa. One belief was that ARV therapy was too complicated to be successful in places with poor health infrastructure and a second was that patients wouldn’t be motivated enough to adhere to complex drug schemes.

Those stereotypes have proven false, Cotton said, and ARV therapy has moved forward. The World Health Organization’s 3 by 5 program, which aimed to get 3 million people on ARV therapy by 2005; the beginning of the Global Fund to Fight AIDS, Tuberculosis, and Malaria; and PEPFAR, the President’s Emergency Plan for AIDS Relief, all helped push ARVs into parts of the continent where they had never been available before.

“After eight years, we really have seen an … increase in the number of people on treatment in PEPFAR countries. It has been truly a dramatic development,” Cotton said.

Despite that progress, Cotton said, the remaining gaps in treatment are glaring. Having so many children born with HIV is one particular failure, she said.

“Last year, 500,000 were born with HIV; most won’t survive past age 2,” Cotton said. “The Clinton Foundation is trying to change that paradigm, but the question is really, Why are any kids born with HIV when we know how to prevent mother-child transmission?”

Other places and populations in need of particular attention include the continent’s many rural areas, some of which have far from even rudimentary health care facilities. Refugees and displaced people are another group that needs particular attention, Cotton said.

Though more people are receiving ARV therapy, Cotton said that many people are still receiving the drugs too late. In addition, diagnostic testing, such as through CD4 counts, which measure levels of certain immune system cells, is often not done. Further, she said, people are not receiving the latest antiretroviral drugs, which tend to be more expensive and rolled out first in the developed world. The new drugs have fewer side effects, so that means patients in Africa are still suffering from the older drugs’ side effects while patients in the developing world are suffering less.

“We’re beginning to see many side effects from older regimens which are out of favor in the developed world,” Cotton said.

Though patients with HIV have proven very motivated to take the steps that will save their lives, many barriers to care still exist. There aren’t nearly enough doctors and nurses to serve the demand. Supply chains are unreliable, making drugs sometimes unavailable after patients have hiked long distances to reach a clinic. The clinics themselves are hampered by lack of reliable electricity supplies, laboratory services, and medical supplies. Some patients never make it, because of the distances involved and the cost of transportation. Monitoring and follow-up are not always done, meaning that treatment failure is not being detected in a timely manner, Cotton said.

In addition, Cotton said, HIV care is often provided as a stand-alone service, with separate funding sources and facilities, offered apart from standard health care. The result is “silos of care,” as she described it, with shining HIV clinics next to run-down health clinics that handle other ailments. While integration of HIV with other care does present challenges, particularly with the prospect of immune-compromised AIDS patients in the same facility as people with infectious diseases, some people believe AIDS and tuberculosis are so closely intertwined in Africa that they should be treated as a single disease, Cotton said.

The future is difficult to think about, Cotton said, with some good indicators — such as a U.S. president-elect who believes fighting AIDS is so important that he got himself publicly AIDS tested, and some negative ones, such as a global financial crisis that will undoubtedly constrain spending on all sorts of programs, including HIV/AIDS. Still, she said, there is a growing level of interest in the disease that is encouraging.

“There is a tsunami of interest around global health in the United States. I am thrilled to see this. I think the future is in your hands,” Cotton said to the audience.