Day 5: Living and Aging with HIV, Dying from TB and NCDs

Judith Currier speaking at Friday's plenary, XIX International AIDS Conference (AIDS 2012) Washington DC.  © IAS/Ryan Rayburn - Commercialimage.net

Judith Currier speaking at Friday’s plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn – Commercialimage.net

Volunteers were handing out t-shirts as we arrived at Friday’s plenary of the XIX International AIDS Conference. When Marie from Results South Africa asked all t-shirt recipients to stand, over a quarter of the delegates rose from their chairs. These individuals represented the percentage of people worldwide who are co-infected with HIV and tuberculosis (TB). This powerful metaphor — 25 % of the people in the room on their feet — highlighted the morning’s theme: integrating HIV/AIDS care and treatment into disease-specific and broader health services.

The “Bell Tolls” For HIV & TB

The session’s first presentation, “Science and Implementation to Turn the Tide”, was delivered by Dr. Tony Harries, senior advisor at the International Union Against Tuberculosis and Lung Disease. Dr. Harries began by stating that 350,000 people had died from HIV/TB co-infection in 2010, and that many of these deaths were preventable.

With evidence-based research and World Health Organization (WHO) recommendations, Dr. Harries argued that co-diagnosis, early ART, and isoniazid preventative therapy (IPT) are answers to the pressing problem of increasing HIV/TB co-infection.

Harries also emphasized a need for “better, cheaper, and quicker” TB diagnostic tests. He explained the benefits of two diagnostics: Xpert MTB/Rif, which provides TB test results in two hours, and Urine TB LAM, which derives a diagnosis in just 30 minutes. “Diagnosis is not just about accuracy,” Dr Harries explained. “It is also about feasibility, speed, costs, and overall impact in saving lives.”

Harris concluded his presentation by urging health professionals to address HIV/TB co-infection by advocating for improved policy and practice, conducting needed research, implementing evidence-based strategies, and tackling poverty, which drives the epidemic. After this call to action, Dr. Harris closed with powerful quote from the famous British poet, lawyer and priest, John Donne: “Any man’s death diminishes me because I am involved in Mankind; and therefore never send to know for whom the bell tolls; it tolls for thee.”

Aging with HIV — Dying from NCDs

Dr. Judith Currier from the University of California then took the stage to present her talk on “Non-communicable Diseases (NCDs) and Aging in HIV.” She began by praising the public health community for supporting improved access to ARVs, which has extended the lives of many people. She shared positive results that show half of all people living with HIV in the US by 2020 will be over the age of 50.

While enjoying the many benefits of longer lives, Dr. Currier also explained that this longevity puts HIV patients at risk for other health problems, including NCDs. The most prevalent NCDs impacting HIV patients today include cardio-vascular disease, cancer, diabetes, and chronic respiratory disease. In 2008, 36 million people died of NCDs. To address the crisis of NCDs among HIV patients, Dr. Currier suggested the following interventions: (1) improved screening and monitoring for NCDs; (2) early diagnosis of NCDs in TB patients and prompt care; (3) smoking cessation interventions; (4) dietary and exercise education; (5) earlier start of ART; (6) tailored ART regiments to reduce the risk of NCDs; (7) expanded global use of safer ART drugs; (8) evaluated treatment for NCDs in HIV patients; and (9) integrated screening and treatment of NCDs in HIV treatment programs.

“HIV and NCD epidemics are colliding on a global scale and failure to address these problems could lead to an erosion of ART benefits,” Dr. Currier warned. In her closing statement, Dr. Currier left the audience with a call to action, punctuated with a collective mandate to “Make healthy aging with HIV an achievable goal.”

Improving Health Systems for HIV

The final presentation, “Optimization, Effectiveness and Efficiency of Service Delivery” was facilitated by Yogan Pillay, Deputy Director General for South Africa’s Department of Health, Strategic Health Programs. Pillay began his speech with praise for South Africa’s recent success in testing 20 million residents for HIV, enrolling 1.7 million people in ART (since 2004), circumcising 500,000 men in the past year, and reducing the nation’s vertical transmission rate from 8% in 2008 to 2.7% in 2011. Despite these promising trends, Pillay cautioned that South Africa’s advances cannot be sustained without greater health system efficiency and effectiveness. “We are treating more people so we need a health and social system that can support [them],” he explained.

To improve health system efficiencies, Pillay urged the community to: increase spending on high impact interventions; improve efficiency of direct service delivery; and reduce spending on indirect costs. Pillay emphasized cost analysis as a means to help health leaders identify the correct spending mix to achieve optimal outcomes. To improve cost effectiveness, Pillay suggested service integration, resource tracking, and conducting an expenditure analysis across funders to identify inefficiencies. Pillay also recommended that the community work collaboratively to improve national health plans by optimizing service delivery models, harmonizing and improving different actors, identifying bottlenecks, highlighting equity concerns, developing research networks and conducting further research on sustainability.

Pillay concluded by emphasizing the importance of political will and collaboration in enhancing the quality and effectiveness of national health systems: “Countries need to take the lead!” he urged, “Partners and countries can fill the investment gap together!”

Yogan Pillay describing South Africa's health system at Friday's plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn - Commercialimage.net

Yogan Pillay describing South Africa’s health system at Friday’s plenary, XIX International AIDS Conference (AIDS 2012) Washington DC. © IAS/Ryan Rayburn – Commercialimage.net

These speeches set the stage for an inspiring final day of the conference while also reinforcing the current global HIV needs and the evidence-based recommendations for an effective response. While the t-shirt exercise was daunting for some, the three presentations left conference participants with an urgency to act, strategies to employ, and evidence to motivate their continued response to the ever-evolving HIV pandemic.

Marie articulated this hope and call as she closed the t-shirt exercise saying: “Let’s move past one in four deaths from TB and celebrate together when we meet again in Melbourne!”

Jessica Charles is communications specialist at MSH’s Center for Health Services.

Emerging World Powers: Leadership to Turn the Tide

XIX International AIDS Conference (AIDS 2012) Washington DC. Special Session: China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?  Aradhana Johri. © IAS/Ryan Rayburn - Commercialimage.net

Aradhana Johri speaking at the XIX International AIDS Conference (AIDS 2012) Special Session: “China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?” © IAS/Ryan Rayburn – Commercialimage.net

The similarities facing China, India, South Africa, and Brazil don’t necessarily jump off the page. However, important commonalities exist that the global health community needs to examine — and perhaps model in low income countries.

China, India, South Africa, and Brazil are emerging world powers that have made important advancements in changing the course of the HIV & AIDS epidemic in their countries.

At a special session of the XIX International AIDS Conference on Tuesday, July 24, hosted by Stephen Morrison of the Center for Strategic and International Studies and anchored by renowned economist, Jeffrey Sachs, high level speakers from each of these countries reflected on significant activities that changed their country’s course in HIV & AIDS management. The leaders also discussed how their countries can help lead the way in the fight against the epidemic.

Three themes developed from the conversation of how these countries were able to successfully manage the epidemic in their countries: (1) A country must invest in health not as the end goal, but as a critical instrument of economic development. (2) Reducing the cost of antiretrovirals (ARVs) is critical to get more people on treatment quickly (each country had a different approach). (3) A strong, educated leadership makes the difference. It is the Ministry of Health and global health professionals job to educate government leaders on health.

The South African Health Minister, Dr Pakishe Aaron Motsoaledi, said the focus on HIV & AIDS is what made the difference for his country. The government worked with partners to dramatically reduce the cost of ARVs by 53% which helped get 1.7M people on treatment. “2009 was our turning point,” he said. “There was a real commitment made by the Government at all levels to improve health impact.”

In China, over 80% of the AIDS budget is from the Chinese government directly, explained Dr Wu Zunyou, director of the National Center for AIDS/STD Control and Prevention, Chinese Centre for Disease Control and Prevention. The trigger point was the SARS outbreak: leadership made rapid changes to control the outbreak and their mindset changed to focus on respecting health as a human right and protecting marginalized groups.

Dr Dirceu Greco, who has served as a member of the Brazilian Ministry of Health’s National Commission on AIDS, explains that Brazil set standards early, owned 100% of the response, and most importantly has developed the world’s largest public health system with over 100 million people in the system. Brazil invested in health, not just HIV and that was crucial to curbing the disease in Brazil.

India dramatically scaled up their HIV program to manage the HIV epidemic. From the beginning, they stuck to a scientific, evidence-based approach when addressing the concentrated epidemic in India. Aradhana Johri of India’s National AIDS Control Organisation, said that the key was to never lose the focus on prevention efforts.

As middle income countries, India, China, Brazil, and South Africa have had some advantages in managing the epidemic; the world’s poorest countries may be able to adapt some of these approaches to change the tide in their countries. As these four countries move forward, they must lead by example and show other countries how to face the challenges that still remain in ensuring sustainability, fighting stigma, and reducing drug costs and, hopefully one day soon, immunization prices.

Jeffery Sachs closed the discussion, saying: “We are at a vital crossroads; the Global Fund is in financial crisis.” He encouraged the presenters not only to be the voice in public health, but within the leadership of The Global Fund. He asked the countries to invest in The Global Fund, so the world can continue to see significant changes in the fight against AIDS, Tuberculosis, and Malaria.

Watch the special session: “China, India, South Africa, Brazil: How Will They Use Their Leadership to Advance the AIDS Response?”

Margaret Hartley is MSH’s knowledge exchange associate.