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Ending AIDS Starts at $6 Billion as Donors Pull Back

Michel Kazatchkine and Eric Goosby may be able to halt the spread of HIV. They just need the money.

The two men control the funds that buy drugs for most of the world’s AIDS patients. Studies in July provided the strongest evidence yet that medicines used since 1994 to treat HIV can almost eliminate the chance an infected person will pass the virus to a sex partner. Given to healthy people, the treatments can also protect against infection, offering the potential to end a pandemic that has killed 30 million people in 30 years.

Governments are now planning projects to assess whether those findings can be replicated in the real world, and what that might cost. Getting the drugs just to those patients who should be treated under existing guidelines would cost another $6 billion a year, according to the United Nations. Treating all those infected, in some of the world’s poorest countries, would cost tens of billions more.

Finding more money will be difficult with economic growth stalling and nations including the U.S., the biggest donor to the AIDS fight worldwide, trying to curtail overall spending to rein in debt. Funding for AIDS in poorer nations fell 10 percent to $6.9 billion in 2010 from 2009 levels, according to the UN.

“We may well be able to overcome AIDS,” Kazatchkine, the director of the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria, said in an interview. Still, “the gap between what the science is telling us we can achieve and what we would be able to achieve is at risk of increasing.”

Cutting Transmission

The latest findings, presented at a conference in Rome in July, show that when treatment with antiretroviral drugs started straight after diagnosis, transmissions of the virus were reduced by 96 percent.

“We all gasped at the starkness,” said Goosby, who oversees the U.S. President’s Emergency Plan for AIDS Relief, which pays for the drugs that treat 3.2 million people worldwide. Kazatchkine’s Global Fund also supports treatment for 3.2 million.

Under current World Health Organization guidelines, however, patients don’t start treatment until their immune systems deteriorate to a certain level, postponing side effects that may include kidney damage and nausea and reducing costs. Abbott Laboratories, Boehringer Ingelheim GmbH, Bristol-Myers Squibb Co., GlaxoSmithKline Plc, Gilead Sciences Inc., Pfizer Inc., Johnson & Johnson and Merck & Co. make antiretrovirals.

More than 34 million people were living with HIV worldwide in 2010, according to the Joint United Nations Programme on HIV/AIDS, or UNAIDS.

Qualifying for Treatment

Of those, about 15 million qualify for treatment under the WHO guidelines that recommend patients start receiving medicines when their CD4 cells -- the immune system cells that HIV infects and kills -- fall below 350 in every microliter of blood. Fewer than half those who qualify, about 6.6 million people, are receiving the drugs, UNAIDS says.

At a special session of the United Nations General Assembly in New York in June, world leaders agreed to expand treatment to all 15 million patients by 2015, and committed to increase funding to at least $22 billion a year from $16 billion now.

The WHO plans to make guidelines available within 12 months on how to use antiretrovirals for prevention, said Gottfried Hirnschall, the director of the Geneva-based agency’s HIV/AIDS department.

Condoms lower the risk of transmitting HIV by more than 90 percent when used consistently. Still, less than half of people with more than one sex partner reported using a condom the last time they had intercourse, UNAIDS said in a report last year.

Policy Choices

While the latest data may give policymakers a new weapon in the fight against AIDS, they also present them with choices about how to allocate resources, and which approach is the best investment, said Helen Rees, co-chair of the South African National AIDS Council’s Programme Implementation Committee.

“In the absence of a guideline that will come in a year, we’ve got to make a decision,” Rees said in Rome. “Do we keep pouring condoms into the system, or is there a glass ceiling? Are we going to now buy 600 million condoms or a billion? It’s that level of decision-making.”

The council’s first priority is to expand treatment to all patients with a CD4 count below 350 within the next five years, Rees said. Patients now start treatment with an average count of about 100, she said. The council is also supporting demonstration sites aimed at seeing whether treating people with counts higher than 350 is feasible, she said.

While the latest trials support starting treatment even earlier than current guidelines recommend, Kazatchkine said the first priority must be to treat the 9 million people who need the pills now just to survive and aren’t getting them.

Setting Priorities

“I cannot prioritize treatment for a patient with 800 CD4 cells when there’s still a line of patients with less than 200,” he said.

Most patients in developing nations receive a three-drug combination of generic copies of Glaxo’s Epzicom, Boehringer Ingelheim’s Viramune and Bristol-Myers’ Zerit. The treatment costs about $61 per patient per year, according to Doctors Without Borders. Newer, less toxic combinations such Gilead’s Atripla, the preferred treatment in developed countries, cost as much as $1,033 a year, the Geneva-based charity said in July.

The drugs reduce the virus to undetectable levels in the blood, and boost CD4 cells. That wards off the opportunistic infections that characterize AIDS, and reduce the chances an infected person can pass the virus on.

Seeking Treatment

Still, most people in developing nations are only diagnosed with HIV when their immune systems have already dropped well below the cutoff of a 350 CD4 count, and more than 60 percent of those infected worldwide don’t even know they have the virus, according to UNAIDS.

“People are coming in for treatment far too late,” said Tim Hallett, a researcher at Imperial College London who has developed mathematical models of what effect the new findings might have and what conditions would be needed to achieve the best results. “They’ve already done most of the transmission they’re going to do by the time you see them in the clinic.”

Two other studies presented in Rome showed Gilead drugs, when given to uninfected people at risk of catching HIV, can reduce their chances of infection by as much as 73 percent.

The U.S. Centers for Disease Control and Prevention is designing projects to test the feasibility of pre-exposure use in groups hardest hit by AIDS, including black gay and bisexual men, and black women, said Kevin Fenton, director of the agency’s Center for HIV/AIDS.

Expanded Testing

The CDC is planning projects in four U.S. locations involving about 300 gay and bisexual men each, though it doesn’t yet have funding, said Elizabeth-Ann Chandler, a spokeswoman.

A combination of expanded treatment for the infected, pre-exposure use of the drugs, condoms and circumcision will likely be needed to halt HIV, Hallett said. It will also require a massive expansion in testing to identify patients earlier, adding to costs that neither Kazatchkine nor Goosby can meet at the moment.

When Kazatchkine passed the hat around at the Global Fund’s triennial replenishment meeting in New York last year, he got $11.7 billion, less than the $13 billion he needed to keep putting patients on treatment at current rates, and a little more than half of the $20 billion he wanted to make serious inroads into the pandemic.

European Governments

While in Rome for the conference, Kazatchkine met with members of Silvio Berlusconi’s government to seek funds. Italy was the fifth-largest donor to his fund until 2009, and hasn’t contributed since then, he said. The nation’s Cabinet last month approved 45.5 billion euros ($62.1 billion) in spending cuts and tax increases to balance the budget and convince investors the country can tame its debt.

The U.S. is now talking to European governments, along with those such as China, Saudi Arabia and South Korea that haven’t been major contributors previously, to increase their spending, Goosby said.

“We are now in a position where the global community needs to share in this responsibility more aggressively and bring resources toward it,” he said in an interview. “We are so close to this goal, that now the conversation must shift to, ‘You need to do your part so we can get across the finish line.’”

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