The announcement by five pharmaceutical companies that they will offer resource-constrained countries substantial discounts on antiretroviral drugs against HIV has the potential to improve access to these life-extending therapies. To date the cost of the powerful drugs that have reduced HIV-related deaths and disease in Western countries (about $US 10,000 to $20,000 a year) has priced them far out of the reach of the majority of people living with HIV/AIDS.

Even with hefty subsidies, identifying and counseling those who are infected with HIV, providing antiretroviral therapy (ART) and ensuring its proper use pose a complex and expensive challenge for any country with high HIV prevalence. Such subsidies could reduce the cost of the drugs to $150 to $200 a month -- still too expensive for most people living with HIV/AIDS -- and that estimate does not include HIV counseling and testing, laboratory tests essential for monitoring the therapy and desperately needed improvements in health infrastructures.

Before the pharmaceutical companies' announcement, many governments -- including, most controversially, South Africa's -- had decided that they could not afford to provide universal access to ART for the prevention of mother-to-child transmission of HIV (MTCT) and the treatment of people living with HIV/AIDS. With the proposed drug discounts, these governments and others in resource-constrained countries would need to revisit the question. But a promise of lower drug costs, absent a large influx of external funding to strengthen the health services needed to deliver ART, is not likely to make their decision any easier.

Given current economic and resource constraints, governments will have to make difficult choices about the HIV/AIDS care and prevention services they can support. In this article, I will look at the needs of those infected with and affected by HIV and how best to prioritize limited resources for maximum impact.

A Bioethical Dilemma

The key question in this debate is a bioethical one. Everyone living with HIV/AIDS deserves access to ART. But is it ethical for governments to spend hundreds of thousands of dollars per person per year for HIV-related disease in countries where the per capita health expenditure is less than $10?

While growing up and working as a physician in Ghana, I watched the rapid decline in the quality of universal health services with limited reach and questionable effectiveness. Over-stretched resources led to universal healthcare that was free, of poor quality and unacceptable to everyone. This situation is still evident in many resource-constrained countries, despite attempts at healthcare reform.

Given the current state of healthcare in the countries most affected by HIV/AIDS, can they afford to further stretch limited health resources by providing free ART? Even if resources were made available by the donor community and banking institutions to purchase the drugs, would this be a rational use of resources? And is the plight of HIV-positive people with no access to ART any different from that of millions of people who die every year because of the unavailability of relatively cheap medications for malaria, diarrhea or TB? Or are we applying different rules to HIV/AIDS?

These questions are important ones. But the heat and intensity of the debate over drug access tends to obscure another equally important point: that the vast majority of people living with HIV/AIDS lack even the most basic healthcare and support services. While we wrestle with the ethical dilemma posed by the cost of ART and the resources needed to properly manage its use, we must not ignore the urgent need for many more affordable services that could improve and extend the lives of people living with HIV/AIDS right now. And we must not abandon the families and communities struggling to cope with the emotional, social and economic impact of the epidemic.

What Can We Afford?

The U.S. government spends about $900 million a year on prevention alone and about $7 billion for care. In contrast, a total of $500 million is spent by governments and donors for both prevention and care in non-industrialized countries. Until recently, little of that $500 million has been spent on care.

Several reasons have been given for the slow response of donors to provide funds for care and support. First, care and support needs are so great, they don't know where to start. Second, if all the necessary resources were provided for care, they would quickly consume the resources available for prevention. Third, many donors believe that the governments of the affected countries should be responsible for care and support programs to ensure sustainability.

Recent dramatic increases in resources for care and support, especially by the U.S. government, signal recognition of the urgent need to mitigate the impact of the epidemic. The world can no longer afford to sit back and ignore the devastating health, social, economic and development impact of the HIV/AIDS epidemics.

Guided by basic public health and bioethical principles, we should ask the following questions: What care programs will have the greatest impact on the majority of people, what is feasible, and what can we reasonably afford and sustain?

A government's decision about the level of services it can provide will also depend a great deal on the stage and severity of the epidemic in a country, the political and financial commitment of the government, the level of infrastructure to support services and the resources available. Ultimately, the decision is often a political one, and it always rests with individual governments.

I would recommend the following interventions in HIV/AIDS care as the minimum that resource-strapped countries need to undertake: voluntary HIV counseling and testing (VCT), basic health services, HIV clinical management, tuberculosis (TB) diagnosis and treatment, referral networks, and community-based care and support. Even with increased resource commitment by governments and several-fold increases in donor support, these basic services may not be attainable for all. Some countries may have to prioritize further. Others can afford to expand on the list.

Recent efforts such as debt relief for heavily indebted countries and a proposed U.S. "Marshall-type plan" of support for high-prevalence countries, if successful, would dramatically improve access to and affordability of care and support, including antiretroviral therapy. For now, we must begin to strengthen essential services.

A Critical Bridge

The continuing debate is over what is needed, affordable and feasible in care and support programs. The issue is not simply whether we provide universal access to ART, but whether we have resources for ART as well as for behavior change interventions, VCT, case management of sexually transmitted infection (STI), HIV disease management, TB case detection and treatment, community-based care and orphan support. I will limit this discussion to care issues.

One of the most important public health approaches in controlling infectious diseases is to prevent the spread of infection from those already infected to the uninfected. In the United States, nearly 60 percent of individuals infected with HIV are aware of their serostatus. In contrast, less than 5 percent of the more than 30 million individuals infected in non-industrialized countries have been tested for HIV. Consequently, millions of people continue to spread the disease without being aware of it. Voluntary HIV counseling and testing is one of the most effective ways of breaking that chain of transmission.

Basic Care Services for People Living with HIV/AIDS Expanded voluntary HIV counseling and testing services Improved basic health services Improved clinical management of HIV disease Better detection, treatment and control of tuberculosis Strengthened referral networks and community-based care and support

VCT should include pre- and post-testing counseling, HIV antibody testing, and referral and psychosocial support, especially for those who are infected. Providing these services gives people the opportunity to know their own serostatus, allows those who test positive to plan for the future, and reduces risk and vulnerability to HIV. VCT offers an entry point to care and support, especially if access to affordable ART is possible. It is particularly important in identifying individuals with dual HIV/TB infections for referral and treatment, HIV-positive women for MTCT intervention, and vulnerable children and potential orphans in need of support. VCT is therefore a critical bridge between prevention and care.

Challenges in Treating HIV Disease

The most neglected component of care and support for people living with HIV in resource-constrained settings is access to high-quality management of HIV disease and its complications in both healthcare facilities and the community. It has often been said that in Africa, hospitals are places where people go to die with AIDS. Yet even without access to ART and some of the expensive drugs for relatively rare opportunistic infections, there is a tremendous amount that can be done for people with HIV/AIDS.

For example, it is estimated that 40 percent to 50 percent of AIDS deaths in Africa are attributable to tuberculosis and that individuals with TB are likely to spread the infection to ten to 15 people before it is diagnosed. Globally, about 11 million people are infected with both TB and HIV. Every year an estimated 10 percent of them will develop active TB and contribute to the 8 million new TB cases that occur annually worldwide. However, TB is curable. Directly observed short-course treatment of a clinical case of TB (known as DOTS) costs US$10 to $20. Improvements in the detection, management and follow-up of dual HIV/TB infection and contacts are among the most critical elements of HIV disease management because they will improve quality of life, reduce AIDS mortality and help contain the parallel and explosive TB epidemic.

Necessary components of a basic care program are improvements in both clinic- and community-based care, in referral networks and in psychosocial support to people living with and affected by HIV/AIDS. In many countries, an already underfunded, overextended and overburdened health system has been further compromised by the HIV/AIDS epidemic. It is obvious that these systems cannot cope with increases in AIDS patients, relative declines in health resources, and the loss of healthcare workers due to HIV/AIDS. Therefore, we need to explore additional approaches to increasing access to care while working to strengthen health systems.

Innovative approaches to providing care in communities, including training and supporting community care volunteers, regular home care visits by local clinic staff, and residential or respite centers for people living with HIV, are being tried in many places. Such community-based services help increase access to care, especially for marginalized populations and those difficult to reach. Full involvement of the community in care and support makes these interventions more sustainable. It also results in a better understanding of the HIV epidemic and its impact, which will reduce stigma and enhance prevention efforts. However, a successful community-based care and support program requires a good referral network and an improved healthcare system.

The Role of Affordable ART

Sustained access to ART is a critical need in the management of HIV disease in all countries. However, providing ART is only part of the solution. Ensuring safe and effective use of these drugs would require considerable investment to improve the health infrastructures of most countries. Access to affordable VCT is absolutely essential for the detection and early management of HIV disease, but policies and programs must be in place to ensure that expanded VCT services do not increase stigma and discrimination against those found to be HIV-positive.

Safe and effective use of ART also would require training of health providers in clinical management of HIV disease, systems for the distribution and monitoring of antiretroviral drugs, laboratory services to monitor patients and drug resistance, and community-based programs to ensure access and compliance to drug therapy. Governments may need to establish systems to minimize 1) development of black markets for subsidized drugs, 2) sale of ineffective imitation drugs, 3) false marketing of ART as a cure for AIDS and 4) equitable access to these drugs.

Finally, there is a potential danger of attention to ART undermining other aspects of care and support, such as basic medical care for AIDS patients, management of TB, and psychosocial and community support. Efforts to expand access to ART should complement, not replace, such critical HIV/AIDS care and support services.

Setting Priorities

The use of ART in managing HIV disease is not included in my recommendation for a minimum care and support package for resource-constrained settings despite the recent proposed discounts on antiretroviral drugs. This is because the proposed subsidized cost is still well beyond the $10 or less per capita health expenditures of most non-industrialized countries.

For these countries, ART access is an agonizing resource allocation and bioethical problem. On one hand, every person living with HIV/AIDS should have access to the best technological intervention available for a disease with such high mortality. On the other hand, by providing relatively expensive treatments for those with AIDS, we indirectly deny resources for other health and development problems. Often the question boils down to whether it is worthwhile to spend several hundreds (or thousands) of dollars on AIDS treatment per year to prolong life at the expense of low-cost interventions to prevent infection and save lives.

Using debt relief to free resources for health services is a promising option, but it may not happen soon enough and not for all the countries that need it. And even with subsidies and increased resources from governments and donors, the dichotomy remains.

Expectations are high for a "magic bullet" solution to the HIV/AIDS problem, either in the form of a vaccine or a cure. The reality is that both are unlikely in the near future, and even when they do become available, we will still need comprehensive prevention, care and support programs. And we will have to pay for all of them.

Until there are dramatic reductions in costs (considerably more than what the five drug companies have proposed), improved mechanisms to deliver the drugs and better laboratory support, universal access to ART is not feasible. More research is needed into HIV disease management approaches that are feasible and affordable in resource-constrained settings.

Countries that currently cannot afford ART still need to develop small-scale or demonstration programs in order to gain experience and develop infrastructures for the safe and effective delivery of ART in the future, when universal access becomes a reality. Meanwhile, much more can and should be done to improve the lives of tens of millions of people living with HIV/AIDS in resource-constrained settings.

--Peter Lamptey

Peter Lamptey, MD, DrPH, is senior vice president of the HIV/AIDS Prevention and Care Department and director of the Implementing AIDS Prevention and Care (IMPACT) Project at Family Health International. Since 1987 he has directed three international HIV/AIDS projects funded by the United States Agency for International Development, which have worked in a total of more than 60 countries.