Dr. Mit Philips, MD, MPH, Health Policy Analyst at Médecins Sans Frontières
There are now nearly 12 million people receiving antiretroviral therapy for HIV, and yet millions of people living with the disease still do not have access to treatment. While important strides have been made in efforts to expand access to and quality of HIV treatment in resource-limited settings, Médecins Sans Frontières (MSF) witnesses first-hand the countries – including but not limited to those with conflict – where people have not experienced the benefits of this global health revolution.
In West and Central Africa, only one-fifth of people living with HIV/AIDS have access to treatment. According to official statistics from 2012, there is a 79% treatment gap in this region. In the Democratic Republic of Congo (DRC), the most optimistic estimates indicate that less than 15% of the 420,000 people who are eligible for antiretroviral treatment today have access. Similarly, only 13% in Chad, 15% in Nigeria, 23% in Guinea and 23% of people in Cameroon have access to life-saving medicines. Many of these countries have relatively low rates of HIV prevalence, but more than half of people facing the ARV treatment gap in sub-Saharan Africa live in West and Central Africa.
In Kinshasa, DRC, late initiation of treatment is quite common; in MSF’s Kinshasa clinic, around 80% of patients present with severe or advanced stage of HIV/AIDS. For many of them, it’s simply too late: a quarter of people do not survive, and 39% of those deaths occur within the first 48 hours. People are literally dying on our doorstep.
A lack of free HIV testing, adherence challenges, barriers linked to inequitable or inaccessible healthcare systems, outdated protocols, disruptions in medical supplies and stigmatisation all contribute to low ART coverage. Low prevalence contexts often suffer from low prioritisation by government and international actors. Pressure from patient associations is often weak or in the early, fragile stages.
These neglected areas are a missed opportunity in tackling the HIV/AIDS epidemic. MSF is urging actors in the global HIV community – including UNAIDS – to urgently develop and implement a catch-up plan that addresses the structural, financial, and programmatic barriers to effective HIV treatment outcomes in these low prevalence contexts.
We welcome the effort underway to promote a viral suppression target of 90% among people on ART, which rightly puts the emphasis on treatment access and quality patient-level outcomes. In addition, UNAIDS should promote specific annual 'challenge' targets in order to double the rate of treatment initiation over the next three years in these low-coverage countries.
Just more of the same will not bring the necessary change in these contexts. All actors should urgently implement strategies that actively promote ART initiation and adherence, including scaling upfree HIV testing, decentralising and simplifying treatment provision, task-shifting, assuring free provision of HIV care, and ensuring a reliable supply of antiretroviral medicines and tests. Particular attention should be paid to identifying, testing and treating infants and children living with HIV.
MSF and others have proved that people can start HIV treatment earlier and get their treatment through community-based platforms and networks, which takes the burden off overwhelmed health facilities and improves people’s adherence. Unfortunately, delays and a reluctance to implement these strategies are most apparent in countries where people need help most urgently. Governments and international actors need to step up and ensure all those who need it have the opportunity to access effective treatment and benefit from the HIV revolution that elsewhere has made the difference between life and death for millions.