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Political leadership on finance and pace of scale-up needed to realise full potential of treatment as prevention
Keith Alcorn, 2013-09-30 17:20:00

Achieving the full potential of antiretroviral treatment as a prevention method will require governments to take political decisions about long-term finance, and be brave enough to lead rather than follow the scientific agenda, according to speakers at Controlling the HIV Epidemic with Antiretrovirals: From Consensus to Implementation, a conference that took place in London last week. 

The conference, organised by the International Association of Providers in AIDS Care (IAPAC) and the British HIV Association (BHIVA) in partnership with UNAIDS and Public Health England, brought together experts for discussion of how to expand treatment access in order to realise the full benefits of antiretroviral therapy (ART) in preventing new HIV infections.

Citing the example of Malawi’s policy to provide treatment to all pregnant women regardless of CD4 cell count – Option B+ – Catherine Gotani Hara, the Malawian Minister of Health, told the conference: “Option B+ was led by policy, not guided by science – Malawi decided to do it.”

“We decided as a country to tailor the treatment for Malawi,” she said. A shortage of CD4-counting machines and the need to simplify treatment guidelines so that nurses could initiate therapy led policymakers to decide that treatment for all pregnant women would be the most suitable approach in Malawi.

“We said we need to go closer to the people. We looked at our workforce – not enough specialised nurses and doctors – and decided to decentralise treatment to the lowest cadres of health care workers without compromising quality,” she went on.

“My big problem was persuading the Minister of Finance to spend money,” she said. What persuaded the Ministry of Finance to permit the expansion of treatment? “Tax take! If they can’t work they can’t pay tax,” she argued to the Ministry of Finance.

But, cautioned Professor Alan Whiteside of the University of KwaZulu-Natal, “40% of adults in Swaziland are engaged in subsistence agriculture, they don’t pay taxes. We need to start making an economic and political case for treatment and we need to understand that we are working in a competitive environment – a competition between AIDS, malaria, TB and health systems.”

“I think the exceptionality of AIDS is over. Finance trumps health every time. We need to be smarter with our advocacy. There is a tension between the short-term and the long-term and between one-year budgets and lifetimes,” he went on.

Arguments about the impact of treatment on the workforce form part of what Reuben Granich, UNAIDS Treatment and Care Advisor, called “third-generation economics”. A study carried out by Harsha Thirurmurthy in Uganda found that people with CD4 cell counts above 500 worked almost six days a month more than people with CD4 cell counts below 200 – and their children were more likely to stay in school.

Today’s investments may have long-run impacts lasting 30 to 40 years that manifest in higher rates of development, less poverty and lower birth rates as a consequence of extended education, Thirurmurthy suggested.