Saturday, 21 April 2012

ART as prevention and the budget

More than 5 million people in South Africa are living with HIV. I was struck while reading an article about Haiti today by this comment on cholera: "the situation itself is no longer really novel". That's kind of what has happened with HIV in South Africa. Especially after the Treatment Action Campaign won the constitutional court's support to force the government to provide anti-retrovirus treatment. Since then it has become normal for the government to routinely re-evaluate the CD4 count threshold for treatment access - currently 350 - and for that treatment to be included as a standard line-item in the national budget.

But there are many other demands on the budget. The government desperately needs to create jobs, the education system is a mess, a rapidly growing number of orphans need some kind of support and there are 16 million people dependent on social grants. Of course HIV prevention is a top priority - HIV/AIDS is decimating the social fabric of communities across South Africa and wiping out generations of productive adults. But there are lots of top priorities.

And I'm just not sure how South Africa will ever afford to give ART to everyone who is HIV positive. Because that seems to be the logical extrapolation from the WHO's new guidelines. The guidelines suggest that HIV discordant couples - where one partner is positive and the other is not - should have access to treatment for the HIV positive partner, irrespective of his or her own immune status because studies have shown that ART dramatically reduces the chances of transmission. The guidelines assume monogamous, faithful couples where one partner is positive and the other is not. Given that the epidemic in South Africa (and further afield) is driven by widespread high-risk sexual behaviour and, in particular, multiple sexual partners, that seems a little unrealistic.  If it works as prevention and prevention is necessary because HIV positive people have multiple partners, ART will have to, eventually, be provided to everyone who is HIV positive and sexually active. Unless I am missing something (and here I'm more than open to being corrected by people who know more about the medical side of HIV than I do)

So if the SA government is going to use this approach - and they have committed to reducing the infection rate to zero in 20 years - they'll probably have to give ART to a lot more people than just the few discordant couples who test together.. If that's true, we have a problem because I'm just not sure that even South Africa, one of the most economically powerful nations on the continent, will be able to afford it.

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