8/8/2019 Developing Solutions

1/2

Mambo?The single Kiswahili word for How are

you? arrives in a weekly text message fromthe AIDS clinic in Nairobi.

From Kajiado, 200 miles away, the clinicspatients, mostly members of pastoral Maa-sai communities, respond with Sawa(OK)or Shida (problem). If, after two days, thepatient does not respond, a nurse followsup with a telephone call. This simple systemconfirms that patients remember to take theirdrugs and are feeling well.

The scheme, which began in May 2007,takes advantage of the fact that, even thoughthe roads between Kajiado and Nairobi arepoor, the mobile telephone service is inex-pensive and reliable.

The texting scheme is the brainchild of

researcher Richard Lester, who noticed thatabout one-half of his patients in Nairobiowned mobile telephones and about 90% hadaccess to a shared telephone.

With funds from the US Presidents Emer-gency Plan for AIDS Relief (PEPFAR),Lesterand the University of Nairobi in 2007 launcheda randomized trial to test whether mobiletelephones can help improve follow-up andoutcome in patients in remote rural areas. Pre-liminary analysis of the data suggests that thosewho participate have lower viral loads, making

them less likely to develop drug resistance ortransmit the infection.

This has huge implications, says Lester,assistant clinical professor at the University

of British Columbia. Hospitals and clinics inKenya and Ethiopia are planning to adopt thescheme, he says.

Mobile telephones are just thelatest strategy in the developingworlds fight against HIV/AIDS.In the past three decades, thesecountries have launched aware-ness campaigns, built testing and counsellingfacilities, expanded their research capacity, col-laborated in international trials and negotiatedfor better access to drugs. With no vaccine ormicrobicide in sight, governments are devisinginnovative approaches, including door-to-door

testing and social networking sites.

Innovative approachesIn April this year, South Africa, until recentlythe poster child for AIDS denialism, launchedthe countrys biggest HIV testing programme.President Jacob Zuma publicly disclosed hisHIV statusnegative to lessen the stigma.The government also announced free male-circumcision services as part of its preventionprogramme.

To those who have been on the front lines ofthe disease from the beginning, the landscapeis dramatically different.

When as a very young doctor I saw my firstHIV patient with Kaposis sarcoma, I thoughtit was something unique. I did not anticipatethe devastation that would unfold before me,says Salim Abdool Karim, director of the Cen-tre for the AIDS Programme of Research inSouth Africa (CAPRISA). Yet, [if] I have seenthe devastation, I have also seen the miracle ofhope offered by antiretrovirals, Karim says.

Despite undeniable gains, however, thecourse of the epidemic remains largelyunchanged. In sub-Saharan Africa, for everyperson who gains access to antiretroviraldrugs, two get infected with HIV, Karim says.

New complications arise all the time. HIVhas revived tuberculosis (TB; see page S18),

making room for deadlier, drug-resistantversions. As in richer nations (see page S14),doctors in some developing countries are see-

ing early heart attacks and kidney failure inHIV-positive individuals.

Its like we are running backwards on thetreadmill, Karim says. We are not stemmingthe tide of the epidemic.

Broken promisesPrevention programmes in most developingcountries rely largely on international funds,which are vulnerable to donor fatigue and theglobal economic downturn.

Despite lofty promises, many donor agencieshave not delivered. For example, the GlobalFund to Fight AIDS, Tuberculosis and Malaria

pledged US$10 billion a year when it was setup in 2001, but has delivered only US$3 billiona year so far.

In 2009, funds from US-basedcharities except from the Bill& Melinda Gates Foundation had decreased by 3% since2007/2008, and funds from

European charities had decreased by 7% since2006,according toan April 2010 report fromthe International Treatment PreparednessCoalition of HIV-infected people and theirsupporters.

Abandoning the AIDS response now will

inevitably lead to a return to headlines aboutpeople dying of AIDS that we read at thebeginning of the decade, the report warns.

PEPFAR is one of the few schemes to havemaintained funding. Launched in 2003 bythen-President George Bush, it was extendedfor a further five years in 2008. This legisla-This legisla-tion authorizes up to US$48 billion to combatglobal HIV/AIDS, TB and malaria.

In a time of tightening budgets and eco-nomic constraints, this request for the eighthyear of PEPFAR is the largest request to datein a presidents budget, says Eric Goosby,PEPFARs US global AIDS coordinator.

PEPFAR programmes continue to scaleup prevention, treatment and care forHIV/AIDS. According to a September 2009analysis, PEPFAR has directly supportedantiretroviral therapy for more than 2.4 millioninfected individuals.

As welcome as donor aid is, however, itcan skew national priorities. As an example,Karim points to South Africa, where HIVresearch infrastructure expanded impres-sively, with international studies on both basicand clinical research.

But much of the research agenda meetsinternational rather than domestic priori-

ties, Karim notes. For example, South Africais researching HIV vaccines, but not the high

DevelopingsolutionsThere is more to combating HIV in the developing world

than providing affordable drugs. T. V. Padma looks at the

innovative new strategies being employed.

Text messages sent to mobile telephones are

helping clinics in Nairobi follow up on patients inremote villages.

TomFox/Dallasmorningnews/Corbis

We are not

stemming the tide

of the epidemic.

HIV worldwide

S16

15 July 2010OUTLOOKHiV/aiDs

www.nature.com/outlooks

8/8/2019 Developing Solutions

2/2

levels of infection among its young women orwhy a substantial increase in condom distribu-tion from 8 million in 1994 to 376 million in2006 has not reduced its rate of new infec-tions in high-risk groups.

National governments are no better at fund-ing their AIDS programmes. At an April 2001summit in Abuja, Nigeria, 52 African coun-tries pledged to allocate at least 15% of theirnational budgets for health. In 2007, only three(Botswana, Djibouti and Rwanda) were on

track, and three others (Burkina Faso, Liberiaand Malawi) had reached some targets.

These slow and bureaucratic governments areno match for the rapid shifts in the epidemic.

HIV/AIDS in Central and Southeast Asiahas spread from injecting drug users to theirsexual partners. In countries such as India andPakistan, the epidemic once spread mainlythrough commercial sex work and drug use, butis increasingly affecting heterosexual couples.

Affordable drugsDeveloping countries also need to sustain andexpand treatment programmes that depend

on cheap HIV drugs, the demand for whichcontinues to grow.Over past years, international charities have

taken the lead in providing cheap medicines tothe poor. For example, the Clinton Foundationhas negotiated lower prices with 8 firms on 40drug formulations and with 12 suppliers for test-ing kits. This has translated into cheaper drugsfor two million people, nearly one-half of theinfected population in developing countries.

Much credit also goes to India and Brazil,which thumbed their noses at drug companiesand encouraged other developing nations todo the same.

Before 2005, Indian laws recognized patentsonly for the process used to make a drug, not

for the drug itself. Indian companies used thisloophole to produce cheap generic versions ofexpensive antiretroviral drugs.

These days, 92% of those receiving treatmentin low- and middle-income countries takegeneric drugs made in India the pharmacyof the developing world.

In 2000, Brazil threatened to issue a com-pulsory license a clause in international pat-ent law that allows countries to waive patentsduring national health emergencies arguing

that its growing AIDS epidemic was a nationalemergency.

It carried out its threat in 2007, issuing acompulsory license to import efavirenz which prevents HIV from replicating froman Indian firm. In 2008, Brazils patent officealso rejected a patent for tenofovir.

Following in Brazils defiant footsteps, abouta dozen developing countries have issuedcompulsory licenses. Brazil revolutionizedglobal AIDS treatment and shaped globalAIDS treatment policy, says Amy Nunn,assistant professor of medicine at BrownUniversity in Rhode Island.

Things could go wrong again, however. In2005, India agreed to recognize internationalpatents, meaning its companies can produceonly generic drugs that are already on the mar-ket. In five or ten years, this is likely to create aserious shortfall in affordable drugs.

It is a very complex issue, says MauroSchechter, professor of infectious diseases atthe University of Rio de Janeiro. We needmore innovation but at the same time, peopleshould have access to treatment, Schechtersays. How do you do both at the same time?We have not found the answer.

One potential solution is UNITAID, a

not-for-profit patent pool set up in March2010, in which drug companies forgo their

patent rights in selected countries, and allowlocal firms to make medicines with mutuallyagreeable licence fees.

Networks of hopeDeveloping countries are also coming up withinnovative solutions to their own, and others,problems in different arenas.

For example, in the late 1990s, the Boston-based non-profit group Partners in Healthfounded the HIV Equity Initiative to provide

treatment and care to infected people in Haiti.This small charity has grown into a network ofnine health centres that serve 1.2 million peo-ple under a national programme supported byHaitis health ministry.

In 2007, a doctor from Haiti set up a similarrural clinic with volunteers in the mountainsof Lesotho, an African country with no medi-cal school and about 80 doctors to attend to itstwo million people.

India, Brazil and South Africa are also col-laborating on research projects, including HIVvaccines, combating HIVTB and creatingmaps of viral diversity.

Brazil provides locally made HIV drugsto almost a dozen countries in Central andSouth America, and in Africa. In March thisyear, several Portuguese-speaking countriestogether set up a network on HIV and sexuallytransmitted diseases.

At an individual level, too, the urge to helpand support each other is obvious. In Kajiado,for example, those who receive the weeklyMambo? text forward it to relatives who arenot part of the Kenyan trial.

As people become more connected, theybecome more hopeful, says Lester. Hoperemoves stigma. nT. V. Padma is a freelance writer in New Delhi

and South Asia editor of SciDev.net

Despite undeniable gains against the epidemic, in countries like India (pictured above) and Pakistan, the epidemic is spreading to heterosexual couples.

S17

15 July 2010 HiV/aiDs OUTLOOK

www.nature.com/outlooks