Globe & Mail, June 24, 2010
By James Orbinski and James Fraser
In 2005 at the Gleneagles Summit – and in line with the UN General Assembly’s commitment to the Millennium Development Goals – the G8 nations committed to ensuring universal access to HIV/AIDS treatment by 2010. Their performance on this promise has saved millions of lives. Although laudable, the gains made over the past decade are less than what should have been achieved, and are now threatened by a retreat of these nations from their funding commitments.
Reduced G8 funding is already leading to systemic drug shortages, with deadly consequences for those receiving or awaiting treatment, devastating overstretched health systems, and threatening global health security. Globally, five million people – or only 35 per cent – are getting the HIV treatment they need to begin to live with a modicum of dignity and even a possibility of becoming fully productive members of their communities and societies. An additional 10 million people (seven million in Africa) also need treatment and will almost certainly become sick or die within the next 36 months.
Dignitas International’s current experience in Malawi provides insight into the future. In 2004, when Dignitas began working in the Zomba District of Malawi, there were virtually no HIV-related services. Medical facilities were places of death, not healing.
Since that time, working in partnership with the Malawi Ministry of Health and with medications supplied by the Global Fund for AIDS, TB and Malaria, Dignitas has started more than 13,000 patients on HIV treatment – approximately 52 per cent women and 10 per cent children. Since 2006, more than 350 patients a month have been started on treatment at the Zomba Central Hospital Clinic, and at 22 local community and rural-village health facilities where Dignitas either treats patients or trains and supports Malawian health workers. Although by any definition the health system remains weak, patient care has become manageable. We have achieved living results.
This story of hope is once again changing, for the worse.
Like other high-HIV-prevalence countries, Malawi has been experiencing shortages of antiretroviral drugs due to delayed disbursements from the Global Fund. This has affected our patients: Dignitas’s medical team has had to stop taking on new patients who are sick with AIDS in its rural clinics. Those already on treatment now have to travel up to 40 kilometres to the Zomba Central Hospital, where we can only give them a one-month supply of medicines. At Zomba Hospital itself, as well as cutting the number of people started on treatment by 30 per cent, we have had to raise the bar so that only the absolute sickest and most immuno-compromised are started on treatment.
Drug shortages not only threaten individual patients, but our global health security. To keep patients on treatment, our medical team is forced to substitute equivalent medications. Sporadic drug availability and drug substitutions lead to confusion and new side effects in patients; these both reduce treatment adherence and efficacy, leading to drug-resistant HIV. Drug resistance and side effects in turn drive demand for more costly antiretroviral drugs, ones that underfunded health systems cannot afford. In these conditions, drug resistance flourishes unchecked.
Against this backdrop, drug-resistant tuberculosis poses a concurrent global threat. TB kills more HIV-positive people than any other disease in Africa. Poor TB treatment adherence also generates drug resistance, resulting in multi drug-resistant (MDR) and extensively drug-resistant (XDR) strains. MDR is 100 times more expensive to treat than regular TB. XDR is 100 per cent fatal among patients co-infected with HIV; an XDR patient treated in North America’s best hospitals has only a 60 per cent chance of survival.
TB is airborne and can infect anyone. It is inevitable that the HIV-driven TB epidemic ravaging Africa will find its way back to Canada in more virulent and deadly strains. Turning our backs on this threat means facing a much bigger problem later.
The moral, legal and security arguments that led the G8 and the UN General Assembly to commit to universal access to HIV treatment by 2010 have not changed. A funding retreat by the G8 is shortsighted in light of the tremendous progress the world has made and the threat that still looms.
This October, UN Secretary-General Ban Ki-moon will oversee the 2011-2013 Global Fund Round 10 replenishment meeting in New York. To achieve universal access targets by 2015, $20-billion (U.S.) in pledges is needed. There is a shortfall of $11-billion. Unless the world meets its commitments, the outcome is clear: Millions of people will continue to die unnecessarily. As the host of this year’s G8/G20 summits, the world is looking to Canada to play a leadership role. Canada should increase its funding to 5 per cent of the Global Fund’s budget, or $1-billion, which would be a relatively modest increase from the 4.2 per cent it has pledged and delivered over the past three years. This would enable Canada to be the leader that it is capable of being, and to work to bring both the G8 and the G20 to meet their prior commitments and global responsibilities.
Dr. James Orbinski and James Fraser are the co-founders of Dignitas International.