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Are we all losing
focus on HIV/AIDS?


Financial crisis and growing poverty could reverse decades of HIV/AIDS progress

Fifteen years ago, doctors delivered Hanna Nazarova a startling and unwelcome piece of news. At the age of 19, she was officially HIV positive. As well as letting her know that her long-term prognosis was pretty much non-existent, officials made her sign a form acknowledging her HIV status and that she was aware that transmitting the virus to anyone else was punishable by law.

Prevention campaigns and the conservatism of Belarus’s creaky public health apparatus only confirmed her grim prospects. “At that time, I really felt my life was over and told myself that,” says Nazarova, who had been using drugs throughout her teenage years. The ensuing “dreadful years” passed in a blur. “Since I had only a few months to live, I decided to enjoy whatever time I had left.”

Nazarova descended further into her addiction.

Years passed and Nazarova — despite her own best efforts — lived. The antiretroviral (ARV) drugs introduced in Belarus soon after she learned of her status were working their peculiar brand of antimicrobial magic. Nazarova eventually kicked her addiction and is now open about her HIV-positive status, and works as a Belarusian Red Cross volunteer peer educator.

In an oddly paradoxical way, HIV saved her life, but only because she could access antiretroviral therapy (ART) — something that the majority of people living with HIV are still unable to do. Life-extending miracle

A testament to the life-giving power of ARV drugs, Nazarova’s experience is becoming unexceptional. The HIV response has come a long way since the disease first mysteriously emerged from the jungles of Central Africa more than 30 years ago.

Decades and billions of dollars in research later, it has morphed from a terminal disease into a manageable chronic condition — largely thanks to the advent of ARV drugs.

As an added bonus, evidence now suggests that the very medications that prolong life also potentially hold the key to halting transmission altogether. Nevertheless, even as scientists acquire greater insight into how the virus can be contained — and possibly vanquished altogether — the financial crisis, coupled with donor fatigue and mounting criticism over the costs of HIV programming, is threatening to derail decades of progress.

Moreover, ART programming continues to be stymied by lack of funding and follow-up, poor infrastructure, insufficient testing, official lassitude and stigma. Every year, an estimated 2 million people still die of AIDS-related illnesses — making HIV the leading infectious killer in the world today.

According to the December 2009 Joint United Nations Programme on HIV/AIDS (UNAIDS) Report on the Impact of the Global Financial and Economic Crisis on the AIDS Response, the percentage of countries reporting problems in maintaining ARV programming rose from 11 to 21 per cent. From the total number of surveyed countries, 59 per cent expected an impact on prevention programmes during the next 12 months. These countries are home to 75 per cent of the people living with HIV. Finally, the report’s authors note: “It is anticipated that the crisis, together with the increasing demand for treatment, will have a serious negative impact on antiretroviral treatment in the long run.”

A growing need

A shift towards earlier treatment is likewise putting a strain on overburdened health systems and making key donors question to what extent they can continue funding ART programmes. When the World Health Organization (WHO) amended its ‘when-to-start’ guidelines upwards from a CD4 count of 250 to 350, the number of people officially requiring treatment also rose dramatically (CD4 cells initiate the body’s response to invading micro-organisms such as viruses).

In 2008, the assessment of need was about 9.7 million people. Following the announcement of the new guidelines, the estimate of need roughly doubled — even as the global aid environment began to reel under a continuous fusillade of financial shocks. Moreover, even though the pandemic peaked in 1996, the numbers of newly infected people continue to climb, albeit more slowly than in the past.

For every two people who begin treatment, five more will become infected. In some countries overall prevalence is beginning to nudge upwards again after more than a decade of stable or declining rates. In Uganda, for example, the government reports that prevalence rose to 6.4 per cent in 2009 from 6 per cent four years ago.

In sub-Saharan Africa, a growing proportion of new cases are occurring in older populations, while in the United States, The New England Journal of Medicine reports that prevalence rates among certain groups (most notably young black gay men) are comparable to those found in the most badly affected African countries.

Elsewhere in Eastern Europe and the former Soviet Bloc, UNA IDS reports that the virus is making its stealthy way from ‘concentrated epidemics’ among injecting drug users and sex workers and into the general population. Since 2001, HIV prevalence in Russia, Eastern Europe and Central Asia has roughly doubled, making the region home to the world’s most rapidly expanding epidemic.

“Donor fatigue is real”

It is a sunny spring day in downtown Vancouver, Canada, but the bright light barely penetrates the fluorescent gloom of leading HIV researcher Julio Montaner’s cramped office at the University of British Columbia’s St Paul’s Hospital.

The president of the International AIDS Society and director of the British Columbia Centre of Excellence in HIV/AIDS, Montaner has done groundbreaking research which first showed that highly active antiretroviral treatment (HAART) dramatically reduces transmission. The problem is how to get that treatment to those who need it.

“Donor fatigue is real,” says Montaner flatly. “Governments, multi- and bilateral donors are all looking to cut costs. It is ironic this crisis is occurring at the very moment in history where we can see, for the very first time, a way out of this terrible epidemic.”

Worldwide, the number of people infected with HIV continues to climb, while the number of new infections is generally declining. That means a growing number of people need access to HIV treatment; but it also shows the contribution HIV drugs are making towards reducing transmission. Source: UNAIDS Aids Epidemic Update

The prevalence of HIV is rising within certain groups in the US and Europe, while regions such as Eastern Europe, Russia and Central Asia have seen the prevalence of HIV nearly double since 2001. Source: UNAIDS Aids Epidemic Update

In 2006, Montaner and his team demonstrated that HAART suppressed replication to the point that the virus could not be passed on. A WHO-authored article subsequently published in The Lancet in January 2009 demonstrated through mathematical modelling that the combination of annual universal voluntary testing and immediate treatment with ARVs could reduce HIV transmission by 95 per cent in ten years. Moreover, Montaner and his team are now uncovering evidence that HIV is in fact a ‘chronic inflammatory condition’ that can cause a variety of life-threatening ailments (heart disease, small vein thromboses and an increased likelihood of stroke) even before it wreaks havoc on the immune system — one more reason to begin therapy as early as possible.

Today, UNAIDS has embraced the rapid expansion of testing and ART access (now known as ‘test and treat’) and has made ART for prevention the centrepiece of global advocacy efforts. The main stumbling blocks, advocates contend, are both a growing reluctance to fund long-term ART programmes and the continued inability of the most highly burdened and impoverished countries to mount an effective response based on ‘lack of absorptive capacity’ — in layperson’s speak: inadequate infrastructure, inadequate staffing and growing poverty.

Thanks to antiretroviral drug therapy, Hanna Nazarova of Belarus is looking at a brighter future. She spends much of her time focusing on prevention as a volunteer for the Belarusian Red Cross, counselling others living with HIV or who are practising risky behaviours.
©Jean-Luc Martinage/IFRC








“It is ironic this crisis
is occurring at the
very moment in
history where we
can see, for the very
first time, a way
out of this terrible

Julio Montaner,
president of the
International AIDS
Society and Director
of the British Columbia
Centre of Excellence








AIDS index

• 33.4 million [31.1 million–35.8 million] people are living with HIV worldwide
• 5.2 million people in low- and middle-income countries are now receiving life-saving ARV drug therapy
• 2.7 million [2.4 million–3.0 million] people were newly infected in 2008
• 2 million [1.7–2.4 million] people died of AIDS-related illness in 2008









Last year, the
overall amount
of money that 70
National Societies
worldwide were
able to raise for the
Global Alliance was
36 million Swiss
francs — a 22 per
cent drop from
2008 levels.




A holistic, global approach

In Malawi, Red Cross volunteers work with local men, women and children raising vegetables, as part of a nutrition programme for people with HIV. In Zimbabwe, volunteers support orphans who have lost one or two parents by protecting them with shelter, paying school fees or helping grandparents provide care.

These are just few of the activities of Red Cross Red Crescent volunteers throughout Southern Africa engaged in the struggle against HIV/AIDS. They are also part of the Southern Africa regional component of the Global Alliance on HIV — an approach adopted by National Societies in 2007 — which has been piloting programmes in ten of the highest-prevalence countries in Southern Africa.

As part of the programme, volunteers have been trained to deliver a wide range of services including home-based and community care, support for AIDS orphans, peer-to-peer education, food security, harm reduction and prevention programmes to combat stigma and discrimination.

In 2009 alone, some 7,700 volunteers were trained in programme implementation in Southern Africa; almost 104,000 orphans received psychosocial support; 81,645 people living with HIV/AIDS received psychosocial and treatment-adherence support; and, in some key areas, Red Cross Red Crescent staff and volunteers provide access to ART treatment where governments cannot.

The problem is that funding for these programmes is waning. Last year, the overall amount of money that 70 National Societies worldwide were able to raise for the Global Alliance was 36 million Swiss francs — a 22 per cent drop from 2008 levels. Meanwhile, total Global Alliance funding is falling far short of the original 347 million Swiss francs appeal. “At the time when we are ready to — and should be — scaling these efforts up, we are seeing the global funding commitment decreasing,” says IFRC’s manager of the global HIV, TB and malaria programmes, Getachew Gizaw.

Within the Movement, National Societies and the IFRC must step up resource mobilization and humanitarian diplomacy activities, he says. If comprehensive HIV programmes can be scaled up — at a time when there’s clear evidence that ART helps prevent transmission — the grass-roots network of volunteers mobilized for these projects offers a chance to make a real and lasting impact.

Since 2005, the number of people living with HIV (PLHIV) who are offered psychosocial, treatment adherence and/or home-based support by Southern African National Societies has risen overall to more than 80,000 people.
Source: Global Alliance on HIV Global Report for 2009

The chart shows that funding mobilized by the ten National Societies within the Southern Africa zone — which continues to make the largest contribution to the Global Alliance — has fallen since 2007.
Source: Global Alliance on HIV Global Report for 2009

Pedro Rosário Saide, home-based
care volunteer for the Mozambique
Red Cross Society, brings HIV
support to rural areas. “Many
people suffer in my community,”
he says. “And why do we need
outside help if I can help?”
©Damien Schumann/IFRC

Accountability vs saving lives

According to non-governmental and humanitarian organizations working in the field, the impact of cutbacks is already being felt and bodes ill for the future of ART expansion. Françoise Le Goff, the IFRC’s head of zone for Southern Africa, notes that volunteers are already seeing a drop in the numbers of people enrolling in ART.

“We at the Red Cross Red Crescent are also really beginning to feel it,” says Le Goff. “Donors are shifting their priorities, their focus is becoming narrower and we are seeing them insist on greater accountability — often at the expense of the very programmes themselves.”

Perhaps the biggest disappointment is a US government decision to put the brakes on its HIV funding commitments. The President’s Emergency Plan for AIDS Relief (PEPFAR ), which was widely lauded as the Bush Administration’s only foreign policy success story, pledged US$ 15 billion in 2003 to combat HIV over a five-year period. In 2008, before the global economic meltdown hit, Congress increased contributions to US$ 48 billion.

Although US President Barack Obama pledged to increase annual spending by US$ 1 billion during his election campaign, in 2009 he requested that Congress only approve US$ 366 million for 2010. He cited the recession and the necessity of refocusing efforts on the dire domestic situation.

On the ground, shortages are already being felt. Nathan Ford, head of the medical unit for Médecins sans Frontières (MSF) South Africa, confirms that the situation is even more dire than news reports suggest. “We are not only hearing reports of ARV stock outs [shortages] in PEPFAR countries, but we are seeing far more ‘treatment migrants’ — people who are travelling long distances to access medicines.”

The farther people have to travel, the less likely they are to comply with drug regimens. “This sets up the perfect conditions for resistance and increased transmission,” he says. “In this field, compliance is everything.”

Overwhelmed health systems

According to Le Goff, prevention programmes targeting vulnerable groups are on the wane and, although widespread treatment interruption has not occurred (yet), new enrolments are down — even as the assessment of need spikes. “Health systems are overwhelmed and need support from other humanitarian actors to ensure adherence to treatment at the community level,” she says, adding that increasing accountability demands from donors are more than many organizations can cope with.

The upshot, she says, is that small and more nimble implementing non-governmental organizations (NGOs) are closing their doors and turning clients away. “Prevention is no longer being funded to the same extent and home-based care is really suffering. It is a serious, serious situation,” says Le Goff. She also notes that programmes focusing on nutrition are also increasingly beset with funding shortfalls. Nutritious food not only enables those living with HIV to stay healthy as they enrol in ARV programmes, but also helps avoid medication side effects.

“You can’t address HIV without addressing the basic requirements of food security,” she says. “We’ve all worked so hard to establish a holistic approach to HIV prevention, treatment, care and support and now we are seeing all of that hard work come to nothing.”

Adding to the increasingly dismal aid environment are critics who charge that resources are being siphoned away from other diseases — that HIV programmes are too ‘vertical’ (i.e., that they only benefit those affected by HIV) and that they are gobbling up the lion’s share of scarce resources — claims that Ford refutes as completely unfounded.

“HIV programmes account for one-fourth of MSF funding because we still consider it a humanitarian emergency,” he says. “It isn’t possible to move away from HIV. The very notion that HIV is receiving a disproportionate amount of funding is not correct and not based on epidemiologically sound evidence.”

Stefan Emblad, head of resource mobilization for the Global Fund to Fight AIDS , Tuberculosis and Malaria, also confirms that donors are starting to question current funding levels. “I don’t sense there is donor fatigue with the Global Fund or the issues that we deal with, but I would say that the current fiscal environment is incredibly difficult and donors are letting us know that,” he says. “All things being equal, with the new [WHO] guidelines, costs will go up substantially as we seek to get more people on treatment.”

While Eric Goosby, US global AIDS coordinator, insists that the US Agency for International Development is not planning to ‘cap’ enrolments, he does concede that the US will not push to implement the new guidelines in Africa. PEPFAR is opting instead to cut costs aggressively by encouraging the eventual transfer of responsibility for AIDS treatment to governments and ensuring that existing clinics are up to scratch, rather than opening more. The organization is also encouraging implementers to treat the sickliest patients first — a strategy that, while it makes a certain amount of sense, critics condemn as short-sighted and far more costly in the long run.

Test and treat

Former WHO epidemiologist Brian Williams, co-author of the seminal ‘test and treat’ Lancet modelling paper, says that delaying treatment is tantamount to telling a woman with breast cancer that she needs to become terminal before she can receive chemotherapy. “Look,” he says, “when you factor in that treatment stops transmission then it becomes a no brainer. So why aren’t we doing it?”

Williams notes that delaying treatment and capping enrolment to cut costs will only result in increased levels of tuberculosis, more hospitalizations, a greater need for intensive and palliative care services, higher mortality, more orphans and, of course, far more transmission. “We are talking about regimens that cost no more than one dollar a day,” he says.

Moreover, numerous studies show that access to treatment encourages those most at risk to be tested. Adds Le Goff, “If they can’t get treated then many of them ask: ‘What’s the point of being tested? What can be gained by knowing that you are going to die?’”

Argues Montaner, deferring treatment shaves off only two or three years’ worth of ART costs — at most. When one factors in the beneficial impact to overall health and the fact that ART reduces viral load to the point where HIV is no longer transmissible, the fiscal arguments simply no longer apply. Costs are coming down and newer medications mean regimens are becoming less toxic and easier to ingest. When compliance is assured, the likelihood of resistance decreases and the overall prognosis becomes far rosier.

However, he also maintains that the US government stands in “very limited company” and cannot continue to shoulder the majority of costs on its own. “President Obama needs to lean on the G8 and the G20 to help pay for the roll-out of expanded treatment,” he says, adding that “others” should be encouraged to contribute their “fair share”.

Notes Montaner dryly: “It would take less money to expand treatment to all who need it than it did to bail out Wall Street — and for far greater return.”

Patricia Leidl, with Jean-Luc Martinage
Patricia Leidl is a freelance writer and consultant who has reported extensively about HIV/AIDS and has worked at WHO’s HIV/AIDS Department, the United Nations Population Fund and UN AIDS, among others. Jean-Luc Martinage is former senior communications and advocacy officer for global health at the IFRC in Geneva.














“When you factor
in that treatment
stops transmission
then it becomes a
no brainer. So why
aren’t we doing it?”

Brian Williams,
former WHO



Fighting stigma and reducing harm —
one cup of tea, one needle at a time

By Jean-Luc Martinage

Once a guitar player in a local Kiev rock band and a former long-time drug user, Volodymyr Moiseyev is now a social worker at a syringe exchange point in an AIDS centre in Kiev, the capital of Ukraine.

“I managed to get out of drugs but I have seen many of my friends die,” he says, as he looks for some Ukrainian ‘underground’ rock music to put on his CD player. “I also have a daughter and I know it is so important to prevent her from going through the ordeal I went through.”

Social worker Volodymyr Moiseyev not only exchanges syringes but provides psychosocial support to clients, many of whom are living with HIV.
“I always take some time
to share a cup of tea with them before they go,” he says.
Photo: ©Jean-Luc Martinage/IFRC

Because injecting drug users make up one of the groups most affected by HIV, the Ukrainian Red Cross Society has included the syringe-exchange project, in partnership with NGOs such as Eney (‘drug users anonymous’), as part of its HIV programme.

“Drug users, some of them living with HIV, can safely come to exchange syringes and needles,” says Moiseyev. “But I am also here to talk to them, share their concerns and answer their questions over a cup of tea.”

The Ukrainian syringe exchange is part of a holistic approach that educates people about how to protect themselves, helps them cope and stay on proper treatment, provides a safe haven free of social stigma and keeps them — and their immune systems — as healthy as possible.

With the support of sister societies such as the American, French and Italian Red Cross (and in the past, the Netherlands Red Cross), the Ukrainian Red Cross has also established a visiting nurses programme to help clients who need additional support. The nurses not only bring food parcels, they also help with applications for benefits when necessary and provide all kinds of advice and services.

“Working with people living with HIV and fighting stigma against them has been at the core of our policy,” says Alla Khabarova, executive director of the Ukrainian Red Cross Society.

The reason why the exchange point has been so popular is that it is one of the few places in Kiev where drug users can come and get some support without fear of getting into trouble with the authorities. For those living with HIV, the threat is even greater as they are likely to be rejected by neighbours and family members due to the high level of stigma.

Ukrainian Red Cross visiting nurse Valentina Kulik takes care of her client Katerina’s foot in her flat on the outskirts of Kiev.
Photo: Jean-Luc Martinage/IFRC

“Discrimination in Ukraine against people living with HIV is very high,” explains Volodymyr Zhoutik, director of the All Ukrainian Network of people living with HIV. “Every day we receive testimonies from members whose children are no longer accepted in schools or are refused treatment at hospital when nurses and doctors become aware that they are living with HIV.”

Getting past social stigmas to treatment is critical as some 360,000 people are currently living with HIV in Ukraine, notes UNAIDS country coordinator Ani Shakirishvili. “Ukraine has the highest contamination rate among all countries formerly part of the Soviet Union,” she says. “If the response continues to be inadequate, statistics are likely to rise further, up to 800,000 living with HIV by 2015, which would a big burden for Ukraine.”


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