Paying now rather than forever has never been as relevant
Paying now rather than forever has never been as relevant as a global health solution to the HIV pandemic than in 2013. The relative success of the ongoing replenishment session for the Global Fund is a positive signal, although still insufficient considering the evidence-based targets that are set for the coming years. Finally, it is probably time to change the meaning of the acronym TasP, which currently stands for treatment as prevention. It is too restrictive to reflect our evolving thinking around the use of ART. To be in line with the available evidence, an alternative slogan for 2014 onwards could be: Test and treat All as Soon as Possible (TASP).
The report by Mansour Farahani and colleagues in of 9-year outcomes of the antiretroviral therapy (ART) programme in Botswana is a welcome addition to the scientific literature on ART programmes. It provides national-level data for more than 126 000 patients who initiated ART from 2002 to 2010. Botswana was the first country in sub-Saharan Africa to make a strong national commitment to scaling up treatment to the entire eligible population. There was early commitment from the commercial sector and the national government to provide resources for treatment. Donor support quickly followed. As a result, Botswana achieved very high coverage, 80–90%, of those eligible for treatment as early as 2005. The effect of this high coverage was an estimated decrease in AIDS deaths of more 50% from 2002 to 2006. The programme has maintained high coverage even as eligibility has expanded. Confirmation of this high coverage comes from data presented by Farahani and colleagues showing that the median CD4 cell count at treatment p-Cresyl sulfate rose from 101 cells/μL (IQR 44–156) in 2002, to 191 cells/μL (115–239) by 2010. The increase in CD4 count at initiation contributed to the decrease in overall mortality of those in their first year of treatment from 29% (51 of 171) of patients in the first year of the programme to 3% (349 of 11 679) in 2009. Farahani and colleagues report that mortality for patients receiving ART was highest in the first few months of treatment and then declined sharply with longer time on treatment. This finding is consistent with patterns shown by the International Epidemiologic Databases to Evaluate AIDS (IeDEA) Consortium reporting on mortality among 123 000 patients in treatment cohorts in several different countries. For southern Africa the IeDEA Consortium estimates that mortality in the first year of treatment is more than double the rate for those on treatment for more than 2 years. The Botswana data show an even steeper gradient in mortality with 12·8 deaths per 100 person-years (95% CI 12·4–13·2) in the first 3 months of treatment, 3·46 deaths per 100 person-years (3·25–3·69) after 6 months of treatment, and only 1·16 deaths per 100 person-years (1·12–1·20) in the second year of treatment. This finding provides strong justification for earlier treatment initiation.
The US President\'s Emergency Plan for AIDS Relief (PEPFAR) has been one of the most effective foreign aid programmes in history. It reached 6·7 million people with antiretroviral therapy in 2013, and has also strengthened country health systems, provided billions of dollars in aid to biomedical and behavioural prevention programmes, and helped to drive declines in morbidity and mortality in many countries in sub-Saharan Africa. PEPFAR began as an emergency response, after relative inaction by wealthy nations, and rapidly built disease-response capacity by funding non-governmental organisations. Although PEPFAR, even in the early years, helped to strengthen health systems, multicellular also faced criticism that it created parallel structures; criticism the programme has responded to in recent years by shifting much of its clinical funding to local partners. The programme has increasingly emphasised country ownership and has responded to aid effectiveness concerns, creating innovative shared governance structures, such as those in South Africa. Similarly, PEPFAR\'s recent structured coordination with the Global Fund to Fight AIDS, Tuberculosis, and Malaria is a laudable effort to harmonise bilateral and multilateral health programming.