An AIDS patient

As International AIDS Conference happens in Toronto this August, bringing together more than 26,000 delegates from across the world, thousands of people living with HIV (PLHIV) especially those in developing countries who weren't able to attend this AIDS conglomeration, have concerns on locally available, sustainable and effective options to keep themselves alive while they wait for ARV programmes to deliver on time, that must reach those at the conference.

AIDS Care Watch campaign (http://www.aidscarewatch.org), a partnership of more than 400 civil society organizations across the world, gathered evidence on the various ways PLHIV were resorting to keep themselves alive while ARV programmes begin to deliver effectively (quantitatively and qualitatively). The three key options for PLHIV to stay alive were:

* Addressing HIV-related stigma, especially in the health care setting
* Pushing for greater efforts to integrate tuberculosis and HIV services
* Increased availability to drugs (like cotrimoxazole) to treat/ prevent opportunistic infections

Addressing HIV-related stigma, especially in the health care setting

Five years ago the United Nations (UN) General Assembly held a special session on HIV and AIDS that resulted in the "Declaration of Commitment on HIV/AIDS (2001)." The Declaration made a specific commitment to reduce the social stigma associated with HIV:

"By 2003, [we shall] ensure the development and implementation of multi-sectoral national strategies and financing plans for combating HIV/AIDS that address the epidemic in forthright terms; confront stigma, silence and denial; address gender and age-based dimensions of the epidemic; eliminate discrimination ... "

Despite this commitment, health care settings are where many people living with HIV (PLHIV) still experience some of the worst HIV-related stigma. The three driving forces behind this insidious form of stigma are:

1- Morality: Health care workers often moralise and judge people's behaviours based on existing prejudice among others in society: religious institutions, the media, and the general public. By legitimising moralistic stances with respect to PLHIV, health care workers often deny people the proper care they need and deserve.

2- Helplessness: Clinical helplessness colours health care workers' reactions to PLHIV. This operates on several levels: First, not only are they powerless to cure HIV, health care workers are often unable to alleviate the psychological and physical pain of PLHIV. Second, many are not trained to provide emotional support to PLHIV. Thirdly, health workers in heavily-affected settings have to deal with the impact of HIV in their own communities.

3-Fear: HIV-related stigma is more pronounced in countries with a weak health infrastructure. In such settings, health care workers must face their daily fear of acquiring HIV because of inadequate access to universal precautions such as gloves, sharps disposal, post-exposure prophylaxis (PEP) and safe blood collection kits. Like others, they may be reluctant to test themselves for HIV. This may consequently be projected onto PLHIV.

Some of the recommendations of the ACW advocates are:

National governments, international agencies, health workers, advocacy groups, and others should endorse and call for urgent interventions to address the three driving forces behind stigma among health workers, namely:

- Codes of ethics and professional conduct in health care provision must be put in place, with sufficient forms of redress for professional violations.

- Practical and attitudinal HIV-related training for all health care providers should be encouraged, especially in light of calls to expand the health care workforce in resource-poor settings.

- Universal precautions should be promoted in order to reduce health care workers' fear of infection, as well as availability of supplies (gloves, sharps disposal etc). - Voluntary counselling and testing, care and support for health care providers need to be promoted.

- Provision of PLHIV-friendly health services, including voluntary counselling and testing, and care and support services must be scaled up. PLHIV must be involved in developing, managing and evaluating such services.

Pushing for greater efforts to integrate tuberculosis and HIV services

At the United Nations (UN) General Assembly special session on HIV/AIDS (2001), the leading infectious cause of death among people living with HIV (PLHIV) – tuberculosis (TB) – was not on the agenda. The resulting Declaration of Commitment on HIV/AIDS did not even include the word 'tuberculosis.' It did, however, assert that by 2003 national governments would: " ... in an urgent manner make every effort to provide progressively and in a sustainable manner, the highest attainable standard of treatment for HIV/AIDS, including the prevention and treatment of opportunistic infections ..."

New strategies and tools are urgently needed to tackle the challenge of TB/HIV co-infection. The WHO recommended collaborative TB/HIV activities must be accelerated, and research stepped up to deliver a new generation of effective drugs and diagnostics to keep co-infected people alive. Closer coordination between national TB and HIV programmes and services is vital. TB and HIV accelerate each other's progression. PLHIV infected with TB have much greater chances of developing active disease than HIV negative people, even at high CD4 counts.

Even where the DOTS strategy is available, current diagnostic tests fail to detect active TB among 60-80% of people with HIV due to the predominantly smear negative pulmonary or extrapulmonary nature of TB in PLHIV. Although recent studies have shown that, in some settings, over three-quarters of people presenting at TB clinics may be co-infected with HIV, only a small fraction of people with TB are also tested for HIV.

An even smaller proportion enters antiretroviral (ARV) treatment. In some countries, people with HIV-associated TB disease experience up to 33% mortality during the first two months of TB treatment. Rifampicin, a cornerstone drug in TB combination therapy, has adverse interactions with HIV treatment regimens containing nevirapine or protease inhibitors.

Further, the current TB vaccine used to prevent childhood TB may not be safe for children with HIV.

ACW offers the following recommendations:

Building on closer integration of TB and HIV programmes in the short-term, our best hope for turning the tide against TB and HIV co-infection lies in the full implementation of WHO recommended TB/HIV collaborative activities and the development of new diagnostic tests, drugs, and vaccines that can identify co-infected individuals and provide them with fast, effective and affordable treatment, or prevent TB infection altogether.

The ACW campaign calls upon national governments, international agencies, donors, and advocacy groups to explicitly recommend and commit to specific actions and investments that will generate:

- Universal access, by 2010, to the full WHO-recommended package of 12 collaborative TB/HIV activities in all health systems – public and private – and in a decentralised fashion at primary care levels;

- Better TB diagnostic tests for use in resource-poor settings that are rapid and effective for diagnosing pulmonary and extrapulmonary TB disease in people with HIV, including children;

- New drugs that shorten TB treatment duration and are safe for use in people being treated for HIV;

- Greater availability and systematic provision of drugs such as isoniazid and cotrimoxazole to prevent/treat TB and other opportunistic infections among PLHIV, including HIV-infected children;

- A TB vaccine safe for use in PLHIV to prevent undue suffering and death among those at high risk;

- Greater support for engagement by civil society organisations – including people living with or recovered from TB and PLHIV – in the design, implementation and evaluation of TB/HIV policies and services.

Increased availability to drugs (like cotrimoxazole) to treat/ prevent opportunistic infections

Cotrimoxazole – also known as Bactrim or Septra – is a wide spectrum antibacterial drug that is highly effective in treating and preventing common opportunistic infections (OIs) among adults and children living with HIV and/or tuberculosis (TB). The drug is widely available and affordable in most settings, costing just $0.0022/dose to $0.0047/dose in the international market.

Since March 2000, cotrimoxazole use has been recommended by the World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) as a life-extending treatment for people living with HIV (PLHIV). In 2004, the WHO, UNAIDS, and the United Nations Children Fund (UNICEF) also recognized the vital role of cotrimoxazole prophylaxis in saving the lives of infants and children exposed to/infected with HIV in a joint statement calling the drug "a crucial potentially life saving intervention…" Yet, despite these provisional guidelines on its use, most countries have not widely implemented cotrimoxazole as a priority, life extending treatment.

Last year, WHO convened an expert consultation to revisit the issue of cotrimoxazole prophylaxis for adults and children. At the meeting, new recommendations were drafted and experts advised WHO to develop clear and consistent messages on the need and value of cotrimoxazole prophylaxis, and to provide technical assistance to countries to increase its use. In addition, it was recommended that regional and global targets should be developed to monitor access to the drug. To date, none of these recommended actions have been taken, nor have revised guidelines been published.

Despite the proven effectiveness of cotrimoxazole in extending the lives of people with HIV and TB, access to this simple, cheap, life-extending treatment is low, especially in the Asia-Pacific region. Furthermore, people living with HIV and TB are not always aware of the benefits of cotrimoxazole. For example, a survey on cotrimoxazole use among PLHIV conducted by the AIDS-Care-Watch Campaign (June 2006), found that awareness of the drug varied significantly. One respondent from India reported: "People who are in networks of [people living with HIV/AIDS] are aware of the potential benefits of cotrimoxazole, those who are not, are left to the good will and knowledge of medical doctors who are often not trained in HIV."

ACW recommends:

People living with HIV and TB in poorer parts of the world are often constantly challenged by a variety of infectious diseases, which place them at greater risk of developing HIV-related opportunistic infections. The AIDS-Care-Watch Campaign strongly recommends a set of urgent actions to increase availability of drugs to treat and prevent OIs, in particular:

* Increased availability to drugs (like cotrimoxazole) to treat/ prevent opportunistic infections

- WHO should immediately publish revised guidelines on cotrimoxazole prophylaxis for children and adults, and set time-bound regional and global targets for universal access to cotrimoxazole prophylaxis.

* Increased availability to drugs (like cotrimoxazole) to treat/ prevent opportunistic infections

- Government bodies should integrate WHO guidelines on cotrimoxazole prophylaxis and treatment for adults and children into national AIDS-related care policies and guidelines.

* Increased availability to drugs (like cotrimoxazole) to treat/ prevent opportunistic infections

- In Health care settings, medical services should actively increase availability and systematic provision of cotrimoxazole to children and adults exposed to and/or living with HIV and/or TB, in accordance with international and national treatment guidelines.

We need to do everything possible to keep PLHIV alive. These are just three key options ACW feels need to be pushed while Toronto AIDS Conference goes forward.

The Abigail Erikson and Bobby Ramakant