Next steps in the battle against AIDS

PharmAccess is dedicated to inclusive healthcare in sub-Saharan Africa, with origins in a mission to increase access to HIV/AIDS treatment. On World AIDS Day 2015, PharmAccess and AIGHD reflect on our shared past, present and the future of fighting AIDS.

When Professor Joep Lange founded PharmAccess in 2001, his groundbreaking scientific work had already laid the basis for triple-combination drug therapy against HIV. Under his supervision a number of clinical trials had successfully been completed that demonstrated the effectiveness of various antiretrovirals. His mother-to-child transmission studies found that the chance of babies contracting HIV falls significantly when mothers and newborns receive antiretroviral drugs in a timely manner. As there were no large-scale treatment programs for Africa yet, Joep became a tireless advocate for bringing HIV/AIDS treatment to the people who needed it most.

PharmAccess joined forces with companies like Heineken to set up workplace programs for their employees and dependents. These schemes proved that treatment in Africa was feasible and that patients could be perfectly adherent to the drugs, recover and resume work. Pioneering activities like this helped lay the foundation for large-scale international action: today, 15 million people living with AIDS have access to these life-saving drugs.

Joep also founded the Amsterdam Institute for Global Health and Development (AIGHD) in 2007 to conduct multidisciplinary research addressing medical, economic, social and political challenges. AIGHD and PharmAccess often work together, combining research and action.

While the end of AIDS seems within reach, challenges remain in areas like funding, drug resistance, sustained patient adherence and an increasing population growing old with HIV and at risk of multiple co-morbidities. In addition to the crucial large-scale treatment programs, different approaches are needed to make sure that AIDS becomes a thing of the past.

Drug resistance
The widespread roll-out of antiretroviral drugs also had an unwanted side-effect. Inevitably, drug resistance started to develop. HIV multiplies very quickly – every two days, millions of new viruses are made in the human body. It can outrun the drugs, especially when people don’t take their medication consistently.

The PharmAccess African Studies to Evaluate Resistance (PASER) program, currently led by AIGHD, was established in 2006 as a multi-country capacity building and research program to monitor HIV drug resistance in sub-Saharan Africa. With a sample of over 3,000 adults and 600 children, it is one of the biggest projects of its kind in the world. Some 25% of all WHO data on drug resistance in Africa is delivered by PASER.

In this unmapped territory, PASER has proven that drug resistance is a fact and that it is gaining ground. In Uganda, for example, about 12% of adults starting treatment have some sort of resistance mutations. Alarmingly, pre-treatment drug resistance in children is even higher. The Monitoring Antiretroviral Resistance in Children (MARCH) study in Nigeria has found it to be up to 15%. This means that one in six children now starting treatment may not be able to fully suppress the virus with the currently recommended first-choice antiretroviral regimen. They will then need the more expensive second-line antiretroviral treatment.

Gathering more data through coordinated, large-scale studies like PASER is crucial in order to inform policy makers to, for example, make correct choices on first and second-line antiretroviral drugs for Africa. Making sure people take their medication consistently is another important example of dealing with drug resistance. Adherence issues are manifold: often pills are out of stock; patients experience drug-to-drug interactions such as when they are on TB as well as HIV medication; there is often hesitation to take pills due to side effects such as nausea and nightmares; patients can be forgetful or receive little support from family and doctors. More research will help make informed policy decisions.

Early treatment
In the absence of a vaccine against HIV, the focus should be on treatment. Joep recognized the importance of early detection and early treatment. By bringing down the viral load, early treatment can eliminate transmission of the virus and eventually bring the AIDS epidemic to a halt: the so called ‘test and treat’ approach is gaining attention. In the last year of his life, Joep initiated two ambitious programs in this area: one in his hometown Amsterdam, the other in his beloved continent Africa.

• In Amsterdam Joep laid the basis for the ambitious HIV Transmission Elimination Amsterdam (H-TEAM) project with the aim of eliminating HIV transmission and AIDS from the city. Early detection can potentially mean the difference between a lifetime of treatment and perhaps a ‘functional cure.’ The sooner an acute HIV infection is detected and treated, the smaller the chance that it will be transmitted to others. H-TEAM is a collaboration between all stakeholders involved in the prevention and care of HIV in the Netherlands, including our partner AIGHD and key affected communities. This week, H-TEAM is organizing an HIV Test Week in Amsterdam, offering free HIV tests with immediate results and options for treatments.
• In Tanzania Joep pioneered a Test and Treat program in one of the poorest regions, Shinyanga, aiming to provide antiretroviral treatment to 20,000 HIV patients over the next 5 years. This will require a comprehensive voluntary testing and counseling approach reaching out to an estimated 300,000 people in the area. This program will apply a practical ‘learning by doing’ approach, unlike several other test and treat programs in Africa that are more clinical trial-like in character.

With an estimated cost of less than 5% of an HIV program’s total budget, PrEP is another promising component of HIV prevention strategies. Another research project underway in South Africa with researchers from AIGHD is exploring the possibilities of PrEP as a prevention tool for people at high ongoing risk of HIV exposure. Under Wits RHI’s TAPS Demonstration Project, it is evaluating whether it is feasible, acceptable, safe and cost-effective for a combination HIV prevention and care program to roll out PrEP for female sex workers who test negative for HIV and to offer immediate initiation of HIV treatment to sex workers who test HIV-positive. Read more on page 72 of the 2015 UNAIDS report.

Such projects are being implemented against the backdrop of UNAIDS’ 90-90-90 targetsand fully in line with the anticipated WHO Test & Treat guidelines.

Potential of mHealth
As mentioned, the good news is that over 15 million people infected with HIV are on treatment. But with over 37 million people infected worldwide, more than 20 million still lack access to treatment. This means that the goal should be to more than double the number of patients on treatment in the years to come. Such a massive increase can only be implemented in a better functioning and more effective healthcare system.

PharmAccess is dedicated to inclusive healthcare in sub-Saharan Africa, and focuses on both demand and supply-side interventions to strengthen the healthcare system as a whole. One way to bring healthcare within reach of those at the bottom of the pyramid is by making use of the unprecedented possibilities of mobile technology in Africa.

Building on the infrastructure of M-PESA, PharmAccess is currently piloting mobile health innovations in sub-Saharan Africa. These center around a mobile health wallet, an innovative technological application that allows funds to be not only targeted to a specific demographic, but also ring-fenced for health. One such pilot in the slums of Nairobi is testing the utilization and cost-effectiveness of paying for HIV/AIDS treatment through a mobile health wallet. The fast-paced developments in this area have huge potential: not only to make healthcare delivery more (cost-) effective, but also to make health markets work for the poor by reaching those who were until recently invisible for governments and donor programs.

‘To those who regularly visit sub-Saharan Africa, the pace of change is indeed astonishing, and there are many reasons to be optimistic about the region. We should, however, also realize that very little has changed for the poor in rural settings, and that the lives of those who left for urban slums are extremely difficult. To include these groups in the ‘great escape’ from poverty is the big challenge ahead.’
Joep Lange, July 2014

 * Joep Lange founded both AIGHD and PharmAccess with the aim of achieving optimal impact through their complementary activities in research and action, respectively. Joep’s vision is part of the DNA of these two organizations. His former colleagues are honored to continue building on his mission, knowledge, network and pragmatism through the Joep Lange Institute, which will become operational in March 2016. Joep not only helped change the face of healthcare in Africa in the past – his way of thinking and acting will continue to have a huge impact in the future.