[John Rock - Asia Pacific NGO Delegation]

There are a few UBRAF indicators that mention treatment  under Goal  B1:Universal access to antiretroviral therapy for people living with HIV who are eligible for treatment. There is even one output indicator that mentions diagnostics: CD4 point of care (POC) technology for HIV diagnosis or patient monitoring is used. But what truths can be hidden under words like ‘eligible for treatment’, ‘receiving antiretroviral therapy’, or diagnostics ‘being used’?

The output indicators that appear in UBRAF can often be met and yet at the same time the ARV treatment of PLHIV be sadly deficient. This creates a problem for the individuals concerned and at the same time there is a public health consequence. People whose regimes are not effective are far more likely to be infectious, as we know.

If we inserted a word so that we said ‘receiving effective treatment’, then we would need to define ‘effective’. So what are the problems and what would effective treatment be? To come to a definition of effective let’s look at some issues that are exemplified by what I have seen over the last few weeks in my region of Asia Pacific.

In Timor Leste there is access to Kaletra as the only second line drug. But if people fail on Kaletra there is no other option, it is the end of the line. But how would you know whether people fail their regime? WHO guidelines say regime failure is when there are two consecutive viral load readings of more than 5,000 copies per ml. There is no viral load machine in the country and the CD4 machine they finally purchased a year ago does not work. They used to send samples to Australia for VL testing, but since they have had a CD4 machine they have stopped. So people start treatment and then there is no way other than clinical presentation and lymphocyte count to know whether or not it is working. By the time it is recognised that a regime has failed people are already sick, more damage has been done to their immune system, and in some cases they have died. There is no HIV specialist in the country. They had stocked out of pediatric formulations while I was there, and the doctor told them to go back to a previous regime they had already failed. I was told that some of the ARVs they get are out of date.

In Fiji the CD4 machine ran out of reagents last year. But that might have been a good thing! One person had a CD4 test done in Fiji with a result of 148. The test was repeated soon after at the Thai Red Cross (very reputable) and that was 450. It may be worse for a doctor to act on totally incorrect diagnostics than to not have any diagnostics at all. What you would do with a patient with 450 is very different from a patient with 148. And did the guy who had thought he was positive for more than a year, and had two negative HIV tests in the previous year prior to having a positive diagnosis, really have a CD4 of 100 on diagnosis suggesting that he might actually have been positive for some time, or not?

These are just two recent examples of countries where there are few options for people failing first line, and none for those failing second line, and with little ability to know when failure happens. It is quite likely that this situation is repeated in many other developing countries right around the globe. Yet in both cases they could legitimately tick the boxes under Goal B1 of UBRAF.

A possible definition of effective treatment could include:

• That first line options are robust (preferably with TDF as part of the regime) as far as resistance is concerned
• That there are second and third line options available
• That there are no stock outs or out of date drugs being provided
• That both reliable CD4 and Viral Load tests are available on a regular basis

Such effective treatment should be affordable and available to all PLHIV who need it irrespective of any social or other determinants. The problem of course is that the costs involved to provide ‘effective’ treatment to all who need it could be hugely more expensive than current investments. Yet the alternative is to lose the progress we have made so far in the fight against HIV and AIDS.

The challenge is twofold. Firstly to develop indicators that will measure whether effective treatment is being delivered, and secondly to persuade countries, who are going to have to shoulder an increasing percentage of treatment costs, to accept them and be bound by them. Unless we meet this challenge people will die unnecessarily and the epidemic will continue its ravage.

We cannot keep indicators that hide elephants.