A new report by the Institute of Medicine has highlighted the huge chasm between the projected number of people infected with HIV/AIDS in sub-Saharan Africa and the available resources for treatment by the end of the decade, forcing African nations to make difficult choices about how to allocate inadequate supplies of lifesaving antiretroviral therapy (ART). It calls for a renewed emphasis on reducing the rate of new infections, promoting more efficient models of care, and encouraging shared responsibility between African nations and the U.S. for treatment and prevention efforts, which could greatly improve prospects for 2020 and beyond.
In 2008, more than 33 million people globally had HIV/AIDS, 67 percent of whom were in Africa. In addition, more than 90 percent of the 2.7 million new infections reported that year occurred in Africa, and only half of Africans who should have received ART according to World Health Organization guidelines then in place were treated. By 2020, the number of infected people in Africa will grow to over 30 million, with just 7 million of the approximately 12 million who should be treated under current guidelines likely able to receive ART, estimated the committee that wrote the report.
The report notes that because treatment can only reach a fraction of those who need it and its costs are "not sustainable for the foreseeable future," preventing new infections should be a central tenet of a long-term response to HIV/AIDS in Africa. In the meantime, decision makers in Africa will need to expand local capacities for choosing how to allocate scarce resources ethically. Because patients requiring treatment now generally were infected years ago, policymakers can do little to reverse the short-term course of the epidemic.
"Already in Uganda and a few other nations, we don't have enough health care workers or ART to meet demands, and health centers are increasingly turning away patients who need these drugs to survive," said David Serwadda, professor and former dean of the School of Public Health at Makerere University, Kampala, Uganda, and co-chair of the committee. "There is an urgent need for African countries and the U.S. to share responsibility and initiate systematic planning now for the future. If we don't act to prevent new infections, we will witness an exponential increase in deaths and orphaned children in sub-Saharan Africa in just a couple of decades."
The report says that despite increasingly more affordable ART drugs and the tremendous success of the U.S. President's Emergency Plan for AIDS Relief in galvanizing global efforts to fight HIV/AIDS, the gap between infections that require treatment and availability of treatment resources continues to grow and could persist for decades to come. The lack of trained health care workers, for example, already is impacting many African nations' abilities to provide care. In addition, the global financial crisis presents significant challenges to the U.S. and other donor nations in maintaining current levels of support for treatment and prevention in the region, making it essential that African governments take up their share of the responsibility.
"It's going to take careful long-term planning to build adequate work-force and infrastructure capacities for HIV/AIDS prevention and treatment programs in Africa," said Thomas C. Quinn, associate director for international research at the National Institute of Allergy and Infectious Diseases and committee co-chair. "It is absolutely critical that more coordinated efforts between the U.S. and African governments be negotiated and formalized now to enable better planning that will reduce the impact of the HIV pandemic in the future."
The committee developed models to track the course of HIV/AIDS in the next few decades under different scenarios of prevention and treatment. Several plausible scenarios indicate that the proportion of African nations' health budgets devoted to HIV/AIDS treatment could begin to shrink, enabling African governments to move toward greater ownership of treatment, care, and prevention efforts, the report says.
For beyond 2020, the U.S. should develop a road map for HIV/AIDS that makes prevention the focus of a sustainable response and requires shared responsibility with African nations for controlling HIV/AIDS. A more binding, negotiated contract approach should be instituted at the country level when providing funding, the report says. Contracts should offer incentives to African nations who invest in prevention and treatment by giving matching funds based on each country's means.
African countries should begin to develop projections of the future burden of their HIV/AIDS epidemics and assess implications of alternative policies on human welfare and resources in their own nations. In addition, leaders in Africa at multiple levels need assistance in expanding national capacities for making ethical choices about how to allocate limited treatment resources.
African nations will require greater resources at all levels -- from national governments to local communities -- to become full partners in fighting HIV/AIDS, the report says. In particular, African governments and international organizations should plan how to meet the greater national work-force requirements for responding to the long-term burden of HIV/AIDS.