Brave endeavor: Treating 10,000 people with AIDS

Brave endeavor: Treating 10,000 people with AIDS

Chris W. Green, Contributor, Jakarta, chrisg@rad.net.id

We can no longer say that the Acquired Immune Deficiency Syndrome
(AIDS) cannot be treated as there are now an increasing number of
options for the treatment of infection by HIV, the virus that
causes the syndrome.

And while medical care must still be lifelong, the cost of
treatment continues to fall. As a result of negotiations by the
Clinton Foundation, the drugs required now cost less than 40 U.S.
cents a day in many countries in Africa and the Caribbean. Even
in Indonesia, the cost of the drugs -- locally produced by Kimia
Farma -- has fallen to below Rp 400,000 (US$47) per month.

Yet these prices are still way beyond the means of most people
with AIDS in the developing world. As a result, less than 300,000
out of the estimated six million people who need this treatment
in countries euphemistically described as "resource-limited" have
access to this treatment. The result is that, even though
treatment is now available, death rates from AIDS in many
countries are still increasing. Many see this as indefensible.

Dr. Jong-Wook Lee, recently chosen as Director General of the
World Health Organization (WHO) agrees. He has been a prime
advocate for the initiative that was launched by WHO and UNAIDS
(the UN Program on HIV/AIDS) on World AIDS Day (Dec. 1) last year
to address this. This is called "3 by 5", reflecting the
objective of providing treatment to three million people by 2005.

Although this is only half of those who need treatment, it
represents what some have described as the most courageous effort
ever considered in global medicine; others view it as just
another unrealistic and impractical slogan.

Whichever, it may represent our last chance to avoid a global
catastrophe. The populations of many countries of sub-Saharan
Africa face annihilation -- and this is not beyond the bounds of
possibility for some tribes of Papua, where infection rates are
approaching African levels. We have little choice but to make "3
by 5" (www.who.int/3by5/about/en/) work.

Yet to achieve this target by the end of next year, as Dr. Lee
admits, will not be possible with "business as usual". It will
require radical new approaches, nimble responses, "thinking
outside the box". It will demand unprecedented flexibility on the
part of government institutions. And it foresees a willingness to
meaningfully involve the community, in particular those living
with HIV.

Of the global target of three million to be provided with
treatment, 900,000 live in Asia. The WHO expects 9,200 of these
to be in Indonesia.

Minister of Health Dr. Achmad Sujudi has accepted this
challenge, and has set his staff the task of providing 10,000
people with treatment next year, with an interim target of 5,000
by the end of this year. Currently a little over 1,000 people are
receiving treatment.

What must we do to achieve these targets? There are many
challenges. The WHO will not be providing funds to buy the drugs
-- indeed the organization will be pushed to pay for the
technical support that it has promised to member countries,
including Indonesia. The Global Fund to fight AIDS, TB and
Malaria (GF-ATM), set up at the request of the UN Secretary-
General Kofi Annan, has so far received only a small proportion
of the estimated more-than-US$5 billion it will require every
year to support this program.

Thus we cannot rely on outside funds; the government, the
community and the private sector must all play a role.

The Ministry of Health has promised a subsidy of Rp 10 billion
for this year, but this will cover less than half of the cost of
the drugs for the 5,000 people expected to get them this year.

Who will provide the other half? Clearly there remains a role
for all of us, including the Spiritia fund that is currently
providing drugs for a number of people.

But money may be the easiest problem to solve. Other
challenges include training a huge number of health care workers
to administer and monitor the treatment; procuring constant
supplies of the drugs; and ensuring that patients take the drugs
every day as required.

This challenge of adherence to therapy is by no means trivial;
even doctors admit that they find it difficult to take all their
antibiotics when they are sick -- and these must only be taken
for a week or so. Today's AIDS therapies must be taken twice a
day, every day for life, without fail. Forgetting only three
times a month risks the virus becoming resistant (immune) to the
drugs and thus, failure of the treatment.

The community must play a crucial role in supporting
adherence, and in other areas, such as informing patients about
treatment options. But while we depend upon voluntary support, we
cannot expect members of the community, and especially people
living with HIV/AIDS, to work for nothing. It will be vital that
we recognize their contribution by providing them with at least a
basic income.

But perhaps the most challenging task we face is that of
identifying the 10,000 people we are going to treat. Although
current estimates indicate that at least 130,000 people are
infected by HIV in Indonesia, less than 5,000 are aware of their
infection. Most only become aware when they start to show
symptoms, usually some seven to 10 years after they became
infected. Therapy is more likely to be successful, and patients
will suffer less if treatment is started before they reach this
stage.

Today in Indonesia, even finding an acceptable place to get
tested for HIV is incredibly difficult. You've really "gotta
wanna" get tested, and put up with inconvenience at best -- and
frequently with discrimination and breach of confidentiality.

Yet to identify the 10,000 who require treatment, the Ministry
of Health estimates we will need to test as many as one million
people, a total which many see as beyond possibility.

It is indeed easy to dismiss "3 by 5" as yet another "pie in
the sky". Nothing on this scale has ever been attempted before. I
am a natural pessimist, but this challenge leaves me neither
optimistic nor pessimistic. I just know that we MUST strive to
achieve these minimum humanitarian goals. Future generations will
judge us harshly if we fail.

-- The writer is an AIDS Treatment Educator, Spiritia Foundation.