A new report on Thailand's experience of giving free anti-retroviral drugs (ART) to people living with AIDS suggests that even developing countries with few resources may be able to deliver the life-saving drugs on a large scale, according to the World Bank and the Thailand Ministry of Public Health.
Of the estimated 40 million people worldwide infected with HIV, UNAIDS says between 5 to 6 million could immediately benefit from ART; but currently only 700,000 people are being treated with the new therapy. In contrast, by May, 2006 Thailand was providing treatment for approximately 78 thousand AIDS patients, more than 90 percent of those in need of treatment.
The new report "The Economics of Effective AIDS Treatment: Evaluating Policy Options for Thailand" says that the country's ability to provide ART affordably to more than 80,000 Thais with AIDS is the result of highly effective prevention campaigns over previous years, a vast network of district level hospitals and rural health clinics with the capacity to provide widespread treatment, a strong NGO community that has worked closely with government on rolling out the expanded ART program, and the close involvement of people living with HIV/AIDS themselves.
"Thailand's ART program is a useful beacon for other developing countries which are looking at how to provide this treatment to people with advanced HIV," says Ana Revenga, co-author of the new report and a World Bank Lead Economist in its East Asia and the Pacific department. "We conclude that Thailand can afford universal treatment, and is rightly in the vanguard of developing countries seeking to provide antiretroviral therapy as the standard of care to large numbers of people with symptomatic HIV disease."
Providing ART in Thailand
Since the first case of AIDS in Thailand was reported in September 1984, more than 1 million Thais have been infected with HIV, and, of those, more than 400,000 have died. In 2004, an estimated 572,500 Thais were living with HIV/AIDS. Among those people, some 49,500 developed serious AIDS-related illnesses during the year, and about the same number died of AIDS-related complications. It is also estimated that 19,500 new infections occurred in 2004.
Thailand has shown strong commitment to providing comprehensive care and support to people living with HIV/AIDS, but it is only recently that it has been able to provide ART to large numbers of people with symptomatic HIV, thanks to a affordable domestically- produced triple-drug combination, called GPO-vir (stavudine + lamivudine + nevirapine), which costs about US$30 per month. This has allowed the Ministry of Public Health (MOPH) to roll out a large-scale campaign to provide triple-drug ART as standard care.
The report says that in a few years, as AIDS patients live longer with ART, the Thai health system will need to provide care not only to 10,000 to 20,000 new cases per year, but also to most of those whose lives have been significantly prolonged by ART. Thailand has good prospects for meeting this challenge. Its ability to even contemplate providing care to all those who need it, however, rests on the success of its past prevention efforts.
The World Bank authors estimate that without such effective prevention campaigns over previous years, Thailand would have had 7.7 million HIV cases and 850,000 AIDS cases in 2005, roughly 14 times more than it has today. Treating this much larger group with ART would have been vastly more expensive, and that burden would have continued to grow over the next decade. Because of its substantial prevention efforts between 1991 and 2002, Thailand has avoided the need to spend an additional US$18.6 billion on treatment over the decade through 2012.
"We estimate that in the absence of the Thais' extraordinarily effective HIV prevention program, the cost of universal access to treatment would be roughly ten times larger than currently and by 2013, would exceed 330 percent of their entire projected health budget
," says Mead Over, a co-author, and a World Bank Health Lead Economist
. "Thailand's past success with prevention is the most important reason the country can afford universal access to ART today. Furthermore it is an essential condition of its continued ability to afford treatment in the future."
Over says Thailand may have saved $43 in treatment cost for every dollar it spent on prevention and it is doubtful that any other Thai government investment has ever achieved such a high benefit-cost ratio. The finance ministries of countries such as China and India, where the HIV/AIDS epidemic is at an earlier stage, should be aware of the high return to HIV/AIDS prevention campaigns when they make allocations of their governments' budgets.
No room for complacency
Although Thailand has been successful in lowering new infections, HIV prevalence among high-risk groups is still high especially among those groups that past prevention efforts did not explicitly target, such as intravenous drug users and male sex workers. There is also evidence that the effect of past prevention campaigns is waning. Recent surveys show that the percentage of male army conscripts reporting sexual relationships with commercial sex workers, after declining for several years, has started to increase again in 2002 and 2003. The same pattern is visible with other female sex partners and among married conscripts who have extramarital sex. Condom use among those male conscripts is not high: only 59 percent report consistent use of condoms with sex workers, and only 25 percent do so with non-regular female sex partners. New risk behaviors by other groups, such as youth, also need to be addressed.
NGOs help maintain adherence
Another key ingredient in Thailand's expanded treatment program is the active involvement of NGO groups such as M�decins sans Fronti�res (MSF), the Thai Red Cross, and peer support groups of people living with HIV and AIDS or PHA, in providing 'augmented' care in the public hospitals for patients with the disease. In addition to supplying drugs, MSF provides ongoing support that includes shared consultations and home visits, case conferences, and training for both hospital staff members and people living with HIV and AIDS.
Patients receiving ART in this augmented public setting are likely to benefit from more active counseling and support from peer counselors, who themselves have HIV, than those receiving ART without the benefit of NGO involvement. The expectation is that this augmentation will help patients strictly adhere to their drug treatment. Indeed, experience over the past three years at MSF indicates that PHA can make a large contribution in supporting adherence to treatment. This contribution comes from the willingness of PHA to help their peers and share their experiences, but the necessary training and coordination demands long-term funding and ongoing technical support.
The report says that the work of PHAs has been a valuable contribution to the government's rapid scale-up of ART. The change in PHA's involvement in health care, from receiver to co-provider, has led to improved acceptance of and support for them within the health care system. Increased control over their health has also brought benefits for PHA in terms of self-image, confidence, and dignity. MSF acts as a bridge between PHA, donors, and the government.
"I've worked with "People With HIV and AIDS in Thailand" for nine years. As anti-retroviral treatment has become more available, I've seen the attitude of many of them change from hopelessness to optimism. They want to share their positive experience of treatment with their friends and so help others to access the medicines which have given them such new life. They have become living instruments for adherence," says Dr. David Wilson, Medical Coordinator, Medecins Sans Frontieres, Thailand.
The new report concludes that the biggest challenge for Thai health policy makers will be to resist complacency and instead build a synergistic relationship between treatment and prevention. This approach may require devolution of responsibility for both treatment and prevention to provinces or lower levels of government so that government units that succeed with prevention will benefit from the saved treatment costs.