Treatment 2.0

Left Field by Patricia Nell Warren

On paper, UNAIDS has some lofty aims—but are they really feasible?

The 7/13/2010 Globe and Mail headline read, “10 MILLION HIV-AIDS DEATHS PREVENTABLE BY 2025, UN SAYS.” It was a demonstration of mindless media spin on the subject of AIDS—especially when international action is meant. And it also demonstrated the rosy fog that major media—and NGOs as well—like to create around on their AIDS pronouncements. Let’s start with the fact that the UK newspaper used the word “preventable,” whereas UNAIDS uses the word “averted.” Prevent and avert are two different things, especially when it comes to AIDS.

The headline’s subject was a new UNAIDS program called Treatment 2.0—meaning the “universal access” to ARVs that is being launched worldwide, with a goal of treating fifteen million people in many countries. The paper quoted Michel Sidibé, executive director of UNAIDS, as saying, “We must reshape the AIDS response.” According to UNAIDS, $26 billion a year must be spent to get this job done.

UNAIDS assembles its usual battery of stats that they extrapolate from spotty data from around the world. By end of 2008, an estimated 33.4 million people in the world were living with HIV/AIDS, with 2.7 million new infections and two million AIDS-related deaths. Five million people are now on ARV treatment in the developing part of the world. To my surprise, however, when I read the UNAIDS Web page for the program, it turned out to be largely futuristic—based on medical technologies and infrastructures that don’t exist yet, or are just now being developed.

Going down the UNAIDS list of aims, these are the conditions that Treatment 2.0 stipulates for success of their program:

1. A new resistance-proof drug has to be developed—preferably for a one-pill-a-day treatment. Here, right away, Treatment 2.0 is in trouble. The pharma industry is deeply worried about the surges of resistance to their drugs—brought on not only by AIDS treatments, but mis-uses of antibiotics in treatment and industry generally. Humanity is sliding down the slippery slope of overexposure to antibiotics. Earlier this year, scientists at The Scripps Research Institute announced that they had identified “two compounds that they say will make it possible to treat drug-resistant HIV strains and slow the evolution of drug resistance in HIV.” But I wonder how such a drug will be widely available and cost-effective by the year 2025 in order to “avert” ten million deaths.

This battle is complicated by the problem of cross-resistance to AIDS drugs by organisms that cause other diseases—the most serious of which is malaria, a disease that is endemic in many parts of the world where AIDS infection is high. Thus a “resistance free” AIDS drug will have to be “free” of resistance to malaria as well. Indeed, we have to wonder if such a drug is possible—given the fact that it’s in the nature of pathogens to develop highly resistant strains. This is their key survival trait, without which they can’t sustain their existence as a species.

2. Treatment must be vastly simplified. Cheaper, easier tests and lab work are said to be in the pipeline—surely a boon for developing countries.

3. Treatment must be viewed as prevention. Patients being treated with antiretrovirals are said to be far less likely to transmit HIV. (I have always wondered how scientists and statisticians can establish this allegedly lower transmission rate with any scientific sureness.) UNAIDS estimates that one million new infections a year would be averted if everyone was treated early.

4. Treatment must be cheaper. UNAIDS admits that treating fifteen million people around the world will cost $26 billion a year. They would like to see countries spend up to three percent of their annual revenues on treatment. But how is this going to work in reality? There is already a shortfall—around $16 billion is being spent on drug programs, and $10 billion can’t be found. Meanwhile, right here in the U.S., three percent of our budget would be close to what our country spent on the TARP bailout in 2009—it is impossible to think that our economically shattered country would ever care about AIDS enough to spend that kind of money. Indeed, U.S. ADAP programs are vanishing at the state level. Even as UNAIDS worries about treating developing countries in Africa and the Caribbean, the U.S. is not treating its own people with HIV. So where is all this money going to come from?

5. Treatment delivery systems must be improved at the community level. This is vital, because the existing global ARV treatment system is already flagging sadly when it comes to adherence. In developing countries, poverty and lack of access to transportation often means that a third of people who start treatment eventually fall away. Some years ago, I remember a lot of talk about how directly observed treatment (DOT) was going to be the goal around the world. But recently the DOT rhetoric seems to have died away.

Bill Gates, cofounder of the Bill & Melinda Gates Foundation, says he endorses Treatment 2.0. He should—he has millions invested in ARV-manufacturing pharma firms. Like everything else that the AIDS industry does right now, Treatment 2.0 will push the profits from drug sales.

Yet what about the UNAIDS claim that the program will “avert” ten million deaths? ARV treatment does not “prevent” or even “avert” death. Sooner or later—except in the case of long-term nonprogressors—death will occur, whether it is caused by AIDS itself, or ARV side effects, or a combination of both. So those people who are infected with the virus are eventually going to die, whether they manage to live on for another twenty years, or just two years. So their deaths will be logged into the casualty estimates regardless. This claim seems like one of those cloud-banks of rosy fog to me.

However, with ten million people kept alive for the meantime, there’s one more big question. Will the planet have to plan enough food, clean water, affordable housing, tools, clothing, education, healthcare, and jobs to support these lives? It would be tragic to save so many people only to see them die miserably of starvation, water-borne disease, exposure, other epidemics or war. By 2012, the world population is expected to swell to eight billion. Ten million people is 1/800th of that. The fraction may not sound like many people, but it is the equivalent of the population of Hungary. Imagine the impact of a country that size being wiped out by famine or war or epidemic.

Even if this program were 100-percent achievable by 2025, we had better be ready to care for all these human beings that UNAIDS aims to save.

All in all, Treatment 2.0 sounds pretty iffy and futuristic to me—more like Pie in the Sky 2.0. Meaning that I wonder how much of this new research, trials and marketing, is going to amount to anything real for the sick people that need it. Not to mention the legislation that needs to support it, if it is to get done by 2025—just fifteen years from now. All the more reason why development of a workable vaccine should be a top priority.

Further reading:

Treatment 2.0 at UNAIDS

Author of fiction bestsellers and provocative commentary, Patricia Nell Warren has her writings archived at Reach her by e-mail at [email protected]

Copyright © 2010 by Patricia Nell Warren. All rights reserved.

December 2010