Mexico City [7 August 2008] Speakers at the XVII International AIDS Conference (AIDS 2008) today underscored the importance of simultaneously scaling up AIDS programmes and strengthening health systems in poor countries, emphasizing that the two goals should be viewed as allies, not adversaries. Experts warned that the global shortage of health care workers hampers both goals and demands a collective response. They also stressed the importance of expanding the role of people living with HIV in the planning and provision of health care as a part of the solution.

“HIV and global health advocates have enough common enemies, chief among them political complacency and inadequate human and financial resources,” said Dr. Luís Soto Ramírez, Local Co-Chair of AIDS 2008 and Head of the Molecular Virology Unit at the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán and Coordinator of the Clinical Care Committee of CONASIDA, Mexico’s National AIDS Council. “In the struggle to recognize health care as a human right, we are natural partners.”

“If the urgency of AIDS and the sheer magnitude of human loss we are now experiencing is not enough to compel us to provide even the most basic level of health care to those living in low-income countries, then we, as a global community, are morally bankrupt,” said Dr. Pedro Cahn, International Co-Chair of AIDS 2008 and President of the International AIDS Society and Fundación Huésped in Buenos Aires, Argentina. “If, in the context of AIDS, we walk away from this challenge, we may never get another chance.”

More Evidence to Weigh in Determining When and How to Start Treatment

According to Anton Pozniak (United Kingdom) of the Chelsea and Westminster Hospital, the questions of “when to start?” and “what to start with?" remain central to people living with HIV and their clinicians as they consider antiretroviral therapy. The move to start treatment earlier is gaining momentum in light of evidence that those untreated patients with CD4 counts above 350 have significantly higher rates of non-AIDS related illnesses such as cardiovascular disease. Pozniak stated that clinical trials are needed to weigh the benefits of starting earlier with the downsides of earlier therapy, including toxicity, resistance and maintaining long-term adherence.

Debates regarding which therapies to use in initiating treatment also continue in those countries where there is an abundance of choice. The first randomized clinical trial to compare the use of boosted protease inhibitors (PI) with non-nucleoside reverse  transcriptase inhibitors (NNRTI), both as the anchor of initial treatment regimens, found virological or immunological benefits to both approaches. Pozniak reviewed data on monotherapy with boosted PIs, which may save money and spare users the long-term toxicity of nucleoside reverse transcriptase inhibitors (NRTIs). He also noted some unexpected toxicities associated with regimens using NRTIs as the backbone of treatment.  Some nucleosides are used extensively in resource-poor countries despite these toxicities, because of lower costs. Pozniak also presented evidence of the effectiveness of tailored combinations for treatment-experienced patients. He concluded that in situations where there is a choice of therapies, treatment of HIV has become focused on minimizing toxicities and maximizing convenience, and that this choice should be offered to all people living with HIV.

Strengthening Health Systems Through Greater Involvement of PLHIV

According to Morolake Odetoyinbo (Nigeria), CEO of Positive Action for Treatment Access, the greater involvement of people living with HIV (PLHIV) can be a key component of efforts to strengthen fragile health systems in low- and middle-income countries. These already fragile systems have been further taxed by the HIV epidemic, which has depleted the health workforce due to illness and death, and magnified the impact of existing malnutrition. Odetoyinbo also warned that lack of treatment literacy and unstable drug supplies are leading to HIV drug resistance and multi-drug resistant TB.

Highlighting the existing involvement of PLHIV as counselors, peer educators, and spokespersons, Odetoyinbo explained how PLHIV can do even more to help strengthen health systems if their involvement is rooted in their existing capacities and skills, and not used to simply fill quotas. According to Odetoyinbo, there also must be an environment that allows professionals living with HIV to be actively involved in health systems. PLHIV should have multi-dimensional roles as advocates, watchdogs and managers, and should also be active participants in decision-making bodies responsible for the planning, implementation, monitoring and evaluation of programmes.

A New Covenant to Make Health Care a Basic Human Right

With 3 million people in low- and middle-income countries now receiving antiretroviral therapy, Gregg Gonsalves (United States) of the AIDS and Rights Alliance for Southern Africa in Cape Town, South Africa, called this feat one of, if not the most, ambitious public health undertakings of our lifetimes. He described how this milestone was reached despite powerful critics who warned that providing antiretroviral therapy was the wrong thing to do. He then described the operational and political barriers to sustaining and expanding access to AIDS treatment in the years ahead.

In his remarks, Gonsalves called on those who recently have begun attacking AIDS funding and programming to recognize the innovations and momentum the AIDS response has brought to the entire field of global health. He urged such critics to join with the AIDS community in moving towards "health for all" — the provision of comprehensive primary care to all who need it — which was a central tenet of the Alma-Ata Declaration issued by World Health Organization member states 30 years ago. While this goal has long eluded the world, Gonsalves urged a new covenant between communities, governments, United Nations agencies, academics, health care workers and scientists to build on what has been achieved in AIDS to make health, not a privilege for a few, but a fundamental human right for all.