Doctors Without Borders Calls on UN and Global HIV/AIDS Leaders to Address Severe Lack of HIV Drug Treatment in Africa

Doctors Without Borders/M�decins Sans Fronti�res (MSF) is calling on the UN and global HIV/AIDS leaders at the International AIDS Conference in Durban to develop and implement an action plan to address the critical lack of access to HIV treatment in those countries in West and Central Africa where coverage remains below 30 percent. This comes as new MSF data from Southern Africa suggests that the implementation of "Test and Start" is feasible but that community-led outreach is necessary to test and link people living with HIV to care and support them on lifelong treatment.

"UN member states need to use this opportunity to recommit to people living with HIV in regions of the world that have been essentially neglected despite the tremendous advances in the last decade globally," said Dr. Cecilia Ferreyra, HIV medical advisor for MSF. "While the number of people on life-saving HIV treatment worldwide doubled over the last five years to nearly 17 million people, those living in West and Central Africa are missing out and in desperate need of treatment."

This situation in several countries in West and Central Africa is reminiscent of MSF's call at Durban 2000 to expand access to affordable antiretroviral drugs in South Africa, where more people than ever are now living long and healthy lives on treatment. As we've seen, civil and community support and affordable medications play a key role in making sure people get and stay on antiretroviral therapies. Failing to reach people in neglected regions puts at risk global goals to reach 30 million people with treatment by 2020 and achieve UNAIDS 90-90-90 targets.
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If serious about meeting the 90-90-90 goal, UN member states must provide support to close deadly treatment gaps by tripling the number of people who start antiretroviral therapy (ART) in the next three years, and implement "catch-up" plans to help low-coverage areas significantly improve the numbers of people receiving treatment. Donor governments must fund the necessary changes needed, including making strong pledges at this year's Global Fund replenishment conference.

Countries must also implement World Health Organization guidelines mandating immediate HIV treatment for people living with HIV, regardless of how ill they are; immediate ART would simplify starting people on treatment in places with weak health systems, keep people healthy, and reduce transmission of the disease.

In MSF's project in Swaziland, data from across nine health facilities in rural Nhlangano district showed that of people who started treatment with a CD4 cell count above 500, 90 percent were still on treatment after six months. In MSF's project in KwaZulu-Natal (KZN) province, South Africa, when offering treatment including to people with higher CD4 counts, over 80 percent of people remained on treatment after twelve months, whether they had started treatment below or above CD4 350. Initiation rates remained stable for people at CD4 levels below 350. These findings suggest that newly-eligible patients will initiate and remain on ART if provided the opportunity, without compromising access to care for the sickest people.
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"In West and Central Africa, three out of four people who need it don't have access to HIV care -- that's more than 4.5 million out of the 15 million new people worldwide who should be started on treatment by 2020," Ferreyra said. "We need to speed up scale-up of ART in low-coverage areas to prevent needless suffering, death, and new infections."

However, testing and offering people treatment and ensuring life-long adherence will not be possible without outreach activities that target testing people before they are ill. Community testing strategies piloted by MSF in KZN are particularly effective at reaching first-time testers, including students, young women at risk of HIV, and young men who may not attend health facilities. Door-to-door testing by community health workers reaches people of all ages, and can even be less expensive than facility-based testing. Importantly, people diagnosed at mobile and stand-alone sites in 2015 had higher median CD4 counts (462 cells/mm�), compared to those diagnosed in facilities (CD4 363 cells/mm�).
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"Patient care works like dominoes, with an entire community involved in testing people where they live and work, and ensuring someone who tests positive is initiated on treatment, and supported to stay adherent to lifelong treatment with suppressed levels of the virus," said Musa Ndlovu, Deputy Field Coordinator for MSF in KwaZulu-Natal. "The lay workers in communities and facilities are the glue holding everything together -- improving both quality of care and access. We need governments to ensure that a workforce of lay people is employed, maintained and expanded throughout the region, to provide testing, treatment initiation and adherence support for all who need it."
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While policies and practices for employing lay workers vary widely, when they are absent from the health system, the impact is substantial. After lay counsellors were withdrawn from facilities in KZN province in two waves during 2015, the monthly average number of HIV tests conducted in facilities MSF supports in Eshowe/Mbongolwane decreased by 25 percent and a further 13 percent respectively. The number of new people starting on treatment in the area also declined by 20 percent in 2015.

Adopting community-based strategies�could help expand coverage in West and Central Africa where barely one in four people among the 6.5 million with HIV in the region have access to treatment. Nearly one third of AIDS-related deaths globally occur in the region, and in order to achieve the global goal of reaching 30 million people with treatment by 2020 -- agreed by all governments at the UN in June -- an additional 13 million people need to be reached with treatment, one third of whom live in West and Central Africa.

According to a recent MSF report, Out of Focus: How Millions of People in West and Central Africa are Being Left Out of the Global HIV Response, service failures, lack of trained health staff and task-shifting, stigma, stock outs, and patient fees/payments often stand in the way of people living with HIV from getting treatment in these regions, and make the fight against HIV an uphill battle.

"Accelerating scale-up can happen in the West and Central Africa region. You start by implementing WHO's recommendation to offer immediate treatment so that people living with HIV stop getting turned away because they are not sick enough to qualify for treatment under outdated criteria, and fit treatment in people's lives through better adapted strategies to bring treatment to where people live and eliminate user fees," said Dr. Mit Philips, MSF health policy advisor and lead author of the Out of Focus report.

In addition to the West and Central Africa regions, MSF is concerned about people who lack treatment for HIV and tuberculosis because of displacement, conflict or instability in areas with very poor treatment coverage.
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At a hospital where MSF works in Kinshasa, Democratic Republic of the Congo, one quarter of people with HIV arrive too sick to be saved, with 39 percent of these dying within 24 hours of being admitted to the hospital. And Central African Republic, although national HIV prevalence is believed to be below 5 percent, 84 percent of deaths in Berb�rati hospital where MSF works are related to HIV/AIDS, while in the north of the country in Ndele, Kabo and Batangafo, MSF teams report HIV positivity rates of 33 percent at the VCT level.

"The HIV situation in West and Central Africa reminds us of the terrible days over a decade ago in Southern Africa, when people were dying and no treatment was available," said Dr. Eric Goemaere, HIV/TB Unit Coordinator for MSF's Southern Africa Medical Unit. "Solutions to close this massive treatment gap exist; we need a massive booster shot for West and Central African if we're going to get anywhere close to achieving the global treatment goals. When there are so many millions of people on treatment today, the right to access that lifesaving treatment should not depend on where people live. We cannot leave these people behind."
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