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.