Johns Hopkins infectious disease specialists who have spent more than two decades leading efforts to combat HIV and AIDS worldwide are warning that limited international relief supplies of antiretroviral therapies currently being distributed in Africa, Asia and the Caribbean will not get to those who can least afford to pay for them.
In an article appearing in the American Journal of Public Health online June 28, infectious disease specialist Jonathan Zenilman, M.D., a professor at The Johns Hopkins University School of Medicine, reports that poorer people have been left out in the past due to insufficient local planning, and that donors and developing countries should learn from these mistakes as the number of people requiring therapy continues to grow.
"Local health officials are faced with the unenviable and difficult task of having to decide who will get therapy and live, and who will have to do without and possibly die," he says. "But this dilemma is unavoidable because supply will fall far short of demand, despite the generous nature and growing scope of aid efforts."
While President Bush's 2003 Emergency Plan for AIDS Relief is spending more than $600 million on antiretroviral therapies for 2 million people, demand in the developing world is even greater and steadily growing, with at least 6.5 million people in need of drug therapy and only 15 percent receiving any. And, Zenilman notes, treatment for HIV is a lifelong need for infected people.
"Even if the president's plan was successful and included with the Global Fund to Fight AIDS, Tuberculosis and Malaria, which calls for providing treatment to 3 million people by 2005, these efforts would only reach half of those in need," says Zenilman, senior author of the journal article.
"Though more people in developing countries are receiving therapy, growing from 400,000 in June 2004 to 700,000 in December 2004, it still amounts to only 4 percent of infected people in India, 5 percent in Ethiopia, and 7 percent in South Africa," he writes.
Internationally, Zenilman has led clinical studies to determine how best to prevent the spread of sexually transmitted diseases in the Americas, Africa, Asia and, in particular, the Middle East.
In the new article, the Hopkins researchers argue that the history of medicine is packed with examples of immediate demand for new therapies outstripping supply. They also point out that rationing of supplies was necessary in all cases, but that public distrust and outrage arose when patient selection methods conflicted with local principles.
Led by Hopkins medical historian Laura McGough, Ph.D., the team reviewed four major developments in medicine that shared the issues confronting distribution of antiretroviral therapies.
The first two pivotal events were advances to treat if not cure then-fatal diseases: the discovery of insulin for diabetes in 1922 and the mass distribution of the antibiotic penicillin in 1943.
In the case of diabetes, insulin's availability turned a once-fatal disease into a chronic, manageable, lifelong one, like antiretroviral therapy has done for HIV. However, the researchers point out that what ensued was a mess. In a completely haphazard fashion, medication went to family members of prominent politicians, private clinics or friends of the physician discoverers, who were caught off guard and almost instantly flooded with requests from the public.
More controversial was the penicillin case, in which two government-appointed committees, one military and the other civilian, decided who received medications. While the civilian committee allocated drugs to the most seriously ill, its decisions were viewed as cold-hearted and distant in letters to committee members and in press headlines. Further inflaming public sentiments was the military's allocation of supplies to soldiers with non-life-threatening sexually transmitted diseases. Eager to return soldiers to active duty, wartime needs outweighed civilian concerns, but this did not sway public opinion that the military was wasting its share of medication.
"While the lack of a plan is the worst-case scenario, even a plan with no public input can backfire if it fails to win local support," says McGough, a research fellow at Hopkins' Institute of the History of Medicine. "It is as important to make sure that the decision-making body is politically legitimate and accountable to the public as it is to agree on the criteria for patient selection to begin with."
The other two precedents are the introduction of hemodialysis for end-stage kidney disease in the 1960s and allocation of livers for transplant in the 1980s and early 1990s.