Impact of the global economic crisis on antiretroviral treatment programs
2009; Future Medicine; Volume: 3; Issue: 6 Linguagem: Inglês
10.2217/hiv.09.45
ISSN1758-4310
AutoresCarlos Ávila-Figueroa, Paul DeLay,
Tópico(s)Poverty, Education, and Child Welfare
ResumoHIV TherapyVol. 3, No. 6 EditorialFree AccessImpact of the global economic crisis on antiretroviral treatment programsCarlos Avila-Figueroa and Paul DeLayCarlos Avila-Figueroa† Author for correspondenceAIDS Financing & Economics Division, UNAIDS, 20 Avenue Appia, Geneva 1211, Switzerland. and Paul DeLayDeputy Executive Director, Programme UNAIDS UNAIDS, 20 Avenue Appia, Geneva 1211, Switzerland. Published Online:30 Oct 2009https://doi.org/10.2217/hiv.09.45AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinkedInRedditEmail As the global economic crisis continues to spill over from the most-developed countries into developing economies, its far-reaching effects are beginning to present a serious risk to the 4 million people currently receiving antiretroviral treatment in low- and middle-income countries [101]. In addition to threatening global gains in the expansion of access to antiretroviral therapy, increasing unemployment and falling levels of household income are now affecting the health and welfare of people living with HIV, particularly in countries with high HIV prevalence and poverty.Advanced economies are suffering their most severe recession in 60 years, with their gross domestic product projected to shrink by an average of 3.8%. Developing countries are facing their own difficulties, with the International Monetary Fund projecting that economic growth will drop from 6.1% in 2008 to 1.6% in 2009 [102], reducing fiscal space and government spending on health.In 2008, available funding for HIV therapy in low- and middle-income countries reached its highest level to date, rising from US$1.6 billion in 2001 to an estimated $15.6 billion [103]. A total of $7.7 billion in international AIDS assistance was disbursed through bilateral channels, the Global Fund and UNITAID, the international drug purchasing facility; the remaining resources were disbursed by domestic sources and the philanthropic sector [103]. Currently, uncertainty is fuelling fears that during the next few years official development assistance will decline or, at best, remain flat, particularly for HIV- and AIDS-spending programs.The effect of reductions in international aid and government spending, on which antiretroviral treatment programs depend, will vary by region and country. Low-income countries, which rely primarily on external aid, will experience growing negative impacts if the commitments made by the international community to sustain and increase access to antiretroviral treatment are not honored. On average, the spending on care and treatment represented 50% of AIDS spending across all countries [1]. Since middle-income countries finance antiretroviral treatment, mainly through domestic public resources, the level of impact will depend on their interdependency with developed economies and the resulting decline in income-generating activities, such as trade, foreign direct investment, currency values, tourism and remittances.Countries in sub-Saharan Africa are particularly vulnerable, along with those in Eastern Europe and Central Asia, which have been significantly affected by large exchange rate devaluations and the resulting increases in the cost of imported commodities and antiretroviral drugs. To a certain extent, treatment programs appear to be less vulnerable in North Africa, the Middle East, Latin America and the Asia and Pacific regions. These countries have concentrated epidemics, low HIV prevalence rates, a reasonably good budgetary situation and, in some cases, a high commitment to maintaining access to treatment, which should allow them to continue financing treatment programs.Maintaining treatment programs may be more difficult in sub-Saharan Africa, a region that contains countries with large percentages of poor households [104], large numbers of people on treatment and, correspondingly, high treatment program costs [105]. Funding from public and international sources has been essential to scale-up AIDS treatment in this region, where low-income countries remain highly dependent on external-aid funding to finance their antiretroviral programs. The more developed economies in the region are heavily export dependent, meaning that fiscal pressure from declining prices in oil, base metals, diamonds and coffee could affect the availability of antiretroviral treatment in the near future.At the national level, countries are experiencing impacts on several fronts, affecting government spending, the capacity of service providers and program implementers, community networks and households. This results in reduced budgets, shrinking incomes, the contraction of social safety nets for the poor, inadequate nutrition and increased morbidity and mortality of people living with HIV. For low-income countries, this creates a vicious circle where limited access to HIV treatment results in the loss of skills and human capital, slowing gross domestic product growth and lowering the resources available to expand HIV treatment. In fact, some macroeconomic estimates suggest that the benefits of scaling up treatment access outweigh its costs [2].The economic crisis is also exposing chronic problems in health systems, notably the scarcity of human resources, inoperative supply systems and drug procurement mechanisms, faulty health information systems, weak budgeting, accounting, planning and the existence of user fees, which create a barrier to accessing healthcare. The process of coping with economic austerity represents an opportunity to begin to address some of these problems by improving the financial architecture, planning and operation of large-scale treatment programs.Faced with a shortage of funds, national programs are adopting measures to increase efficiency and are switching to a more cost-effective allocation of resources. This has involved a shift to generic drugs, enforcing treatment guidelines aimed at a more rational use of antiretroviral regimens, emphasizing adherence to keep people on first-line regimens longer, and analyzing the efficiency and variation of unit costs between healthcare facilities. Closer monitoring and accountability of drug procurement is also taking place, along with better planning and forecasting of antiretroviral therapy needs. Government leadership and ownership of national coordination efforts are crucial components of this improvement process. It is also critical that donors, implementers and suppliers of technical support discuss a common approach for assessing the impact of the crisis on HIV and AIDS.By the end of 2006, approximately 2 million people living with HIV/AIDS were receiving antiretroviral therapy in low- and middle-income countries – a dramatic 54% increase from the previous year. This number had doubled to 4 million by the end of 2008 [101]. However, towards the end of 2009, antiretroviral treatment programs are operating in an uncertain and economically constrained climate. This instability is creating a risk-averse environment and is slowing the scale-up of national programs, thus affecting the trend that previously put an estimated additional 1 million patients on treatment each year.A growing number of reports show that the economic crisis is already affecting antiretroviral treatment programs through drug shortages, slow drug delivery and cost increases to antiretroviral drugs due to exchange rate devaluation. Respondents in a recent survey also report that the availability of antiretroviral treatment is being threatened by budget cuts in 23 of the 72 surveyed countries [106].Neither the international community nor developing countries wish to reverse the progress achieved so far in addressing HIV and AIDS. But the severity of the global economic crisis will cause many countries to face very difficult financial choices. To manage the tension between supply and demand, many implementers are incorporating innovative mechanisms and the best practices from the private sector, including more careful planning and forecasting of antiretroviral treatment needs, and closer monitoring and accountability of drug procurement.With the aim of reducing the price of antiretroviral medicines, several partnerships are exploring the removal of barriers to generic drugs, voluntary licensing, patent waivers and patent pools. Governments are legally entitled to lift patent barriers for public health purposes through the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) flexibilities, which allow countries to either import or produce their own generic versions of HIV drugs. Patent prices can also be reduced when an originator company waives patents by issuing voluntary licences or nonassert agreements to certain manufacturers. A broader form of voluntary licensing is a patent pool, where originator companies voluntarily put their antiretroviral patents into a single pool in return for a royalty. So far, competition from generic drugs appears to be the most significant factor in reducing the price of HIV drugs [3,107].Strengthening the delivery of HIV and AIDS commodities means addressing procurement and supply-chain management, such as warehousing and distribution. Existing distribution systems for health facilities require reliable 24-month forecasts, 12-month supply plans and quarterly reviews to effectively quantify demand. This improved cycle of planning, monitoring and control can prevent stockouts and treatment interruptions, while lowering the price of purchased products [108].Contrary to expectations, the rapid scale-up of antiretroviral treatment in developing countries has not been followed by poor adherence – in practice, the patient-related factors resulting in nonadherence are similar in poor and rich countries. Although, programmatic barriers to continuous access to antiretroviral treatment, including geographical and financial barriers in developing countries, often play a greater role. Appropriate antiretroviral treatment should be able to maintain plasma HIV-1 RNA levels below the limit of detection (<50–400 copies/ml), minimizing the development and replication of additional resistance mutations. Patients on antiretroviral treatment are at risk of developing drug-resistant HIV if they have treatment interruptions, a risk which increases with the number and duration of interruptions [4,5].The development of drug resistance would require a switch to second-line antiretroviral treatment, which in poor countries is less available and three–five-times more expensive than first-line therapy. So far, the number of people requiring second-line therapy has been contained to an estimated 5% [6]. Poor adherence and treatment interruptions can lead to viral-load rebound, immune system damage and the subsequent development of AIDS-related illnesses, placing a higher burden on health systems and causing increased mortality.It is widely recognized that placing people on antiretroviral treatment provides health benefits and has the potential to impact upon HIV transmission. This is particularly true for interrupting mother–child transmission, which has been virtually eliminated in the USA and a number of other countries [7,8]. Despite the economic crisis, the effort to eliminate mother–child transmission of HIV by 2015 should be strengthened. The world cannot accept that every year 300,000 newborn children in Africa are infected with HIV through vertical transmission. Stopping the expansion of antiretroviral treatment and downsizing the current number of people receiving antiretroviral treatment may result in an increased 'community viral load' and a corresponding increase in the number of people newly infected with HIV.Adapting to the changing environment of the economic crisis is both a tremendous challenge and an opportunity to introduce innovative managerial practices and efficient operations that deliver value for money and reduce waste. Use of a public health approach for resource-limited settings establishes the principles necessary to expand coverage while saving lives, ensuring quality of care and promoting equity [9].As we make our way through the third decade of the AIDS epidemic, we now have affordable antiretroviral combinations capable of adding years to the lives of people living with HIV. In many cases these are the productive years of teachers, nurses and doctors in high prevalence countries. We need to adapt to the realities of the diverse mosaic of countries and delivery systems. The laboratory monitoring regarded as the standard of care in Europe and North America is unfeasible in large parts of Africa that lack the human resources and laboratory capacities to implement it. However, life-saving therapies can still be provided through evidence-based, clinical protocols that balance technical quality with an availability of resources.Although the economic recovery is expected to be slow, global economic conditions have improved quicker than expected, mainly due to public intervention [102]. While many countries may be questioning whether they can maintain the measures needed to support people living with HIV and AIDS, the world cannot afford to have a shortfall in antiretroviral treatment programs, which are so essential to the lives of millions of people around the world.AcknowledgementsThe authors would would like to thank Carol Nicolls for her editorial assistance.Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. 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AIDS Medicines and Diagnostic Service (AMDS). www.who.int/hiv/amds/en/ (Accessed 12 September 2009).Google ScholarFiguresReferencesRelatedDetails Vol. 3, No. 6 Follow us on social media for the latest updates Metrics Downloaded 407 times History Published online 30 October 2009 Published in print November 2009 Information© Future Medicine LtdAcknowledgementsThe authors would would like to thank Carol Nicolls for her editorial assistance.Financial & competing interests disclosureThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.No writing assistance was utilized in the production of this manuscript.PDF download
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