Commentary
Let's Not Forget the Third World
A physician shares why HIV is still such a problem in developing countries.
By Frank Rhame, M.D.
From the beginning, AIDS has revealed many things about us and our culture, including our attitudes about sex education, sexual orientation, immigration, and drug use. The disease also forces us to see problems that otherwise are too easy to ignore. One is the disparity between the health care provided in the industrialized world and that provided in less-fortunate countries. The story of HIV/AIDS in developed nations is one of great medical accomplishment. In the Third World, however, it has unfolded quite differently.
In industrialized nations, we have come to understand the human immunodeficiency virus (HIV) during the last two decades better than any other pathogen and can now largely control it in infected persons. Thanks to the work of researchers who have discovered drug combinations that keep the virus in check, HIV no longer kills infected persons the way it used to through chronic immune system destruction and opportunistic infection. With sufficiently early diagnosis and timely use of antiretrovirals, HIV infection no longer necessarily progresses to AIDS. Although we haven’t found an effective vaccine and can’t always change human sexual behavior, we have managed to reduce transmission by needle sharing, reduced mother-to-child transmission to less than 1 percent, and virtually eliminated transmission through transfusions.
But before we congratulate ourselves too much, we must confront the fact that HIV illness is still a major problem and cause of death in the Third World. In sub-Saharan Africa, the situation is the most challenging. Home to 11 percent of the world’s population, the region accounted for 67 percent of HIV infections, 70 percent of its new infections, 90 percent of children living with HIV, and 75 percent of AIDS-related deaths last year.
The global response has been heartening, with tens of billions of dollars being donated to provide antiretrovirals to more than 3 million people in the region. But the number of dollars spent and the number of people treated tell only part of the story. In order to understand why HIV is still as prevalent and deadly as it is in the developing world, we have to realize that more new HIV infections were diagnosed in Africa last year than there were people put on antiretrovirals. We won’t be able to treat our way out of this epidemic unless enough infected persons are given treatment that is effective enough to substantially reduce transmission rates. Currently, the gap between the need and the response is so great in that part of the world that treating even large numbers of people won’t be enough to stop the virus’ deadly trajectory.
Why the Disparities
One reason HIV is still a great problem in developing countries is the circumstances under which care is provided. I have worked with a group in Uganda that has about 60 clinics throughout the country. Their clinic next to the Congo border is near an active war zone. The clinic in Gulu in the north is in the midst of the territory of the Lord’s Resistance Army, the folks who for 25 years have been recruiting 8-year-olds to fight the Ugandan government and chopping off arms and using rape as intimidation techniques. The clinic in the northwest is in a Darfurian refugee camp, a locus of extreme deprivation with the highest HIV prevalence in Uganda. The medical and clinic staff who work in those clinics are well-trained and manage to provide much-needed care, but they serve patients whose lives are terribly difficult. Transportation is bad, and people are scattered over vast areas, so some patients have to walk long distances to get to a clinic. The clinics themselves are crowded, so patients may have to wait all day for a brief assessment. And for many, nutrition is marginal, making the physical demands associated with getting care all the more trying.
Also, HIV/AIDS continues to be a problem in the Third World because antiretroviral therapy is very different in these countries. For instance, stavudine is part of most treatment regimens in developing countries because it’s cheap and has very little short-term toxicity. It’s not even considered an alternate treatment in Western treatment guidelines. After several years on the drug, a substantial portion of its recipients develop peripheral neuropathy and lipoatrophy, the disfiguring loss of subcutaneous fat. Because therapies that don’t have such side effects are more expensive, they are not regularly used in poor countries.
In addition, people in developing countries do not receive treatment for HIV as early as those who live in industrialized nations. The current World Health Organization (WHO) criterion for treatment initiation, promulgated in 2006, is a CD4+ count below 200. Although it’s up to health officials in each country to decide whether to follow those guidelines, most Third World nations are heavily or totally influenced by the WHO recommendations, which haven’t been updated in three years. (In the West, treatment guidelines are updated about every six months.) If the WHO were to raise the treatment threshold to 350, it would double the number of persons in need of treatment. If the START trial, an international study of whether earlier treatment can reduce morbidity and mortality, finds that all HIV-positive persons should be treated even sooner, the treatment deficit in the Third World will be all that much greater.
Also, patients in poor countries often remain on failing treatment regimens, increasing the chance of the virus mutating. The WHO criteria for changing therapy because of treatment failure are CD4+ inadequacy, clinical illness, or HIV RNA greater than 10,000. In the United States, we switch patients as soon as HIV RNA is detectable in order to minimize development of resistance. Almost nowhere in Africa is treatment monitored by viral load. Sadly, CD4+ and clinical criteria repeatedly have been demonstrated to be poor predictors of viralogic failure. The result is that dense resistance is developing in those with “silent” viralogic failure, and many patients are switched to scarce secondary regimens when they don’t need them.
Although well-intentioned, the millions of dollars given for providing antiretrovirals in countries that have average annual health expenditures of less than $50 per person per year have produced unintended consequences. These funds create programs that offer better salaries and draw the most talented local providers away from other health activities. In addition, too many AIDS organizations, especially those funded by the U.S. PEPFAR (President’s Emergency Program for AIDS Relief), don’t build local infrastructure that supports overall health. In the cold calculus of dollars per disability-adjusted life-year (DALY) averted, the cost of providing nutritional supplements for anemic pregnant women is $13/DALY and the price of insecticide-treated bed nets in areas of endemic malaria is less than $41/DALY. The cost of HIV prevention is more than $350/DALY. But the world seems more willing to fund HIV/AIDS prevention than those other activities. The question we should be asking is whether spending on this infrastructure directly might have a bigger impact on the prevention and treatment of HIV/AIDS. For example, in much of Africa, the water is unsafe to drink. The WHO and other parties advocate breastfeeding by HIV-positive mothers in areas where safe water and sufficient formula are not available. Yet about 15 percent of babies who are breastfed for more than six months become infected with HIV through their mothers. Thus, in an ironic twist, the WHO is making a recommendation that predictably causes many HIV infections.
A Worldwide Perspective
The problems are not limited to Africa. Much of Asia, eastern Europe, and South America face challenges that are just as daunting, although the situations in those areas tend not to be as desperate. I spent time earlier this year working in clinics and hospitals in Vietnam. UNAIDS calculates that 10 percent of those in Vietnam who need antiretroviral therapy, even by the narrow WHO criterion of less than 200 CD4+ cells, get it. Only 25 percent of pregnant women are even tested for HIV. Inadequately tested blood from paid donors is transfused. In Hanoi’s prestigious Bach Mai Hospital, the AIDS ward consists of four beds in a room so small it’s difficult for two people to pass each other. The average daily census in that tiny ward is seven. Patients—men and women—sleep two to a bed. Confidentiality is nonexistent, and isolation is impossible.
I’ve been lucky enough to see health care on the ground in Vietnam, Russia, Ukraine, Georgia, Uganda, Uruguay, and Ecuador. Perhaps the most valuable lesson I’ve learned working in underprivileged parts of the world, besides gaining an appreciation for how fortunate we are in the United States, is the extent to which people do the best they can even under difficult conditions. The care patients with HIV and AIDS receive in these countries is often remarkably good, and that is a testament to the power of clinical skill. But it still falls well short of that which is available in more prosperous parts of the world.
The human immunodeficiency virus has taught us many things. The focus it brings to the disparities between the Third World and the industrialized world is providing us with one of the more painful lessons. MM
Frank Rhame is research director of the infectious diseases and travel clinic at Abbott Northwestern Hospital and a physician at the Allina Medical Clinic–The Doctors. He is an adjunct professor in the department of medicine and adjunct associate professor in the School of Public Health at the University of Minnesota.