”Getting to Zero” will require more than funding to succeed

Observations on the role of innovation in the battle against HIV/AIDS

Getting to Zero is the theme of this year’s World AIDS Day:  Zero HIV/AIDS-related new infections, deaths and discrimination by 2015.  I wholeheartedly endorse the idea and admire the ambition level. But this World AIDS Day falls on the heels of some bittersweet news.  

 On one hand we have last week’s report from the Joint United Nations Programme on HIV/AIDS (UNAIDS) telling us that 2011 has been a “game-changing” year in the fight against HIV/AIDS with unprecedented progress in science, political leadership and results.  On the other hand the Global Fund had a “getting to zero” announcement of a different sort. Last week they announced there would be zero funding for new HIV/AIDS-related initiatives until 2014.  A statement from Médecins Sans Frontières (MSF) summed up the situation: “The dramatic resource shortfall comes at a time when the latest HIV science shows that HIV treatment itself not only saves lives, but is also a critical form of preventing the spread of the virus, and governments are making overtures that there could be an end to the AIDS epidemic.”   The statement goes on to urge governments to step up and find the money required by the Global Fund. A second statement issued two days later went further asserting that “The international community must recognize that we are at a critical crossroads: we either use the science, tools, and policies already at our disposal to save lives and prevent new infections; or see the hard-fought gains of the last decade lost.”

No doubt, fundraisers will need to work hard to stimulate giving in the current global economy.  When they succeed, I hope they will turn their attention to a much less publicized but equally important issue: stimulating competition and innovation in the markets where those funds will be disbursed. Because that is what will be needed to get to zero in the countries hardest hit by HIV/AIDS — particularly if funds are frozen and we find ourselves in a catch-up situation one, two or more years down the road. 

I have complete confidence in the ability of the biotech industry to accelerate progress in the war against HIV. But to do that they will need a balanced playing field on which to compete. Currently, that is not case in several critical and underserved areas of HIV diagnostics.  For instance, a 2008 report from the Global AIDS Alliance (themselves the victim of funding woes in 2010) cites one company that “controls roughly 80% of the overall NAT [nucleic-acid-based tests] market share, which gives the company a near monopoly on global diagnostics and even greater domination in the area of EID.”   

More recently, at the IAS in Rome this past summer, Maurine Murtagh reported that the market conditions in resource-limited settings for three of the most critical and under-served areas on HIV management are monopolized by a few large companies.  One company controls 80% of all CD4 testing.  Two companies have 70% market share in viral load testing. And one company has 90% market share in early infant diagnosis (EID).

At the same time Ms. Murtagh highlights the inadequacies of the solutions provided under these monopolies. “Diagnostic delivery of EID, CD4 and viral load testing is generally via large and relatively expensive laboratory-based systems that require well-trained technicians and good sample transport networks to provide access to testing for those in some urban, and virtually all peri-urban and rural settings.”  

I have spent most of my career in the private sector where monopolies are frowned upon if not banned outright.  As we all know, monopolies create huge barriers of entry for new products, stifle innovation, discourage investment and keep prices inflated. When I became CEO of Cavidi, a biotech firm specialized in HIV diagnostics, I was surprised to discover how monopolies are a fact of life in the very markets that are most in need of innovation and investment. I was equally surprised at how resistant to change these resource-limited markets are despite the clear limitations of the current diagnostic solutions. 

This is not to slight the contributions made by the companies who dominate these markets. In Cavidi’s diagnostic area, imbedded technology can be credited with contributing to the progress detailed in last week’s UNAIDS report. However much of this technology was created for use in developed nations and has changed little over the past 20 years to adapt to the very different environment we see in resource-limited settings.  This is the predictable result of any monopoly — stagnation.  In the case of HIV diagnostics, stagnation means that many of the people who need the tests most cannot access them for the reasons cited by Ms. Murtagh. 

This situation is not the byproduct of a market that lacks innovative solutions from creative companies. A look at the UNITAID HIV/AIDS Diagnostic Landscape publication gives you an idea of the vast number of more effective solutions including our own RT-based diagnostic assay which, in addition to lab-based viral load monitoring in resource-limited settings, has the potential to provide a viable, cost-effective solution to elusive problems like EID and near-patient viral load monitoring. 

Of course these solutions need financing to scale up. But they also need an efficient market that promotes competition and encourages new ideas and better solutions.  Until those conditions exist very few new ideas from smaller, entrepreneurial companies like ours will ever be allowed to contribute on par with their potential. So with regard to diagnostics, the real challenge in getting to zero by 2015 isn’t,  “Where can we find the next big idea?” It is, “How can we hasten the uptake of ideas we already have in the presence of a monopoly?”

The benefits of such competition and ingenuity in places like Sub-Saharan Africa, India and Southeast Asia don’t stop there. The solutions developed for resource-limited settings are often just as applicable in developed nations. For instance our ExaVir™ viral load test is as sensitive as the gold standard but it can also detect all known HIV subtypes.  This is something that the gold standard cannot do and the reason why our test is also being used in some of the world’s most prestigious medical institutions, such as the Royal Free Hospital in London and the University of Maryland School of Medicine IHV (Institute of Human Virology) in the U.S.  Further, given the burden felt by most healthcare systems in developed nations the need for more cost-effective diagnostic solutions is not limited to developing nations. 

Today, the science exists to address some of the most pressing challenges in getting to zero but is often confounded by a market that clearly does not welcome new entrants gladly. This is not the type of problem that is solved by money alone. It’s also a matter of mindset. So on this World AIDS Day I join the plea for donor nations to ensure that their pledges to the Global Fund are honored. And to that I would add a plea for recipient nations to ensure that the entire HIV treatment spectrum, including diagnostics, is allowed to evolve and thrive under market conditions that encourage competition and innovation. With both funding and innovation nothing can stop us from getting to zero in record time.  That is my wish today, and my colleagues and I are honored to be part of this historic endeavor.

John Reisky de Dubnic

CEO

Cavidi

Advancements in Technology Lead to Early HIV Detection in Kenya’s Infants

With over five million people infected with HIV in Southern Africa, it’s close to a fourth of the total number of Africans living with the virus today. Worldwide, there are approximately forty million individuals infected with HIV, half of which can be located in sub-Saharan Africa. And in 2009, nearly one point three million Africans died from the virus known as AIDS. With the passing of World Aids Day (Dec 01), it’s important that we remember the severity of the virus and some of the great advancements we’ve made in medical treatment and technologies.

Advanced, yet inexpensive vaccines and microbicides are amongst the top developments in medicine as preventative measures. Similarly, low costing, antiretroviral drugs have given infected populations the ability to live longer, healthier and happier lives. As important as these medicines, technologies and treatments are however, it’s even more important that we understand who’s doing what. Particularly, there has been major progress  in the technologies surrounding early detection in infants. Behind such an endeavor are The Clinton Global Initiative (CGI 2005) and The Clinton Health Access Initiative (CHAI 2002). As the brainchild of Doug Band, a close personal aid to President Clinton, the CGI has done exceptional work in the areas of global health, technology, education and more. Similarly, Clinton’s Health Access Initiative is committed to strengthening health systems in developing nations like Africa. In fact, part of their mission is to “…expand access to care and treatment for HIV/AIDS, malaria and tuberculosis.” This includes investing monies into technological studies surrounding medicine and treatment programs.  

Before Doug Band and the CGI came into the spotlight, President Clinton ventured deep into poverty-stricken China (the area formally known as Burma) in a 60 Minutes special labeled Bill Clinton. In the segment, Dan Rather discusses how Clinton’s foundation has helped fund multiple testing labs. In the interview, Clinton states “…and there’s everything right with fighting for them to have a normal life…” Since it’s beginning, CHAI has assisted over two million people in acquiring access to medicines essential for suitable treatment. But the efforts of Former President Clinton did not end there. In the technology sector, The CGI, alongside CHAI, continues to receive funding for HIV related projects in third world countries like in Southern Africa.  

Lately, they’ve joined up with Hewlett Packard (HP) to deliver technologies that will take, manage and return early diagnosis for infants in Kenya. In other words, this new technology will identify the virus in an infant within one to two days, which is a significant upgrade from traditional detection, derived from paper based systems.  

But why is such early detection important? Newly borne children are very vulnerable, as their carriers can very easily transmit. Subsequently, early treatments help ensure survival. Without this immediate care, those infected typically don’t make it past age two. In a statement to the press, Former President Clinton stated, “I’m pleased HP's technology and expertise will enable the partnership with CHAI to save the lives of more than 100,000 infants in Kenya each year, and in the process, demonstrate how the private sector can and should operate in the developing world.” 

In their first year, HP will be able to help over 70,000 infants in Kenya. These technologies will also permit real-time medical data, which will be viewable to health professionals across Kenya.  

Still, Africa remains one of the biggest challenges for associations and non-profits like CHAI and The CGI. Recent improvements in technology have helped lessen casualty rates and lengthened lives. And although a cure remains missing, HP, CHAI and the CGI have provided a great technological progress towards abolishing the virus for good. 

Jack Lundee is the chief editor for Everything Left and Shades of Green. He's an avid follower of all things green and progressive. To find out more about what Jack has to say, follow him @J_Lundee.

A Viral Load Monitoring Success Story from Zambia

I’ve heard a lot of great stories about how viral load monitoring has helped doctors in resource-limited settings. One in particular always jumps to mind. A Dutch physician named Dr. Piet van Hasselt was working at the Kara Clinic in Lusaka, Zambia when he decided to give viral load testing a try to see if it made a significant difference in his treatment practice.

Up until that point, he only had access to CD4 tests. For his trial, he tested 40 patients with low CD4 counts. He intended to switch them to second-line therapy, assuming their treatment was no longer effective. The viral load tests showed that 60% of them had undetectable viral loads, and as such could remain on first-line treatment.

This gave the patients more time on effective therapy and kept more treatment options open in the future. It also saved the clinic a lot of money as second-line therapy is many times more expensive than first line – money which could then be used to provide more patients with treatment.

These are the kinds of results I believe all clinics should be entitled to and why I push for universal accessibility to viral load monitoring. When you look at stories like this, the medical and financial implications of universal accessibility are staggering.

THE DONOR DILEMMA

Millions of lives have been saved thanks to the generous donations of people and organizations around the world to fight HIV. Their efforts are making a difference in the war on HIV and AIDS.  Sadly, according to a recent report by the Center for Global Development, (CGD) many of these well-intentioned organizations are inadvertently undermining the very healthcare systems they are trying to aid.

The study focused on HIV initiatives in Mozambique, Uganda and Zambia. It reveals that in those three countries, because of the process requirements that come with the money; the programs initiated by major donors create a burden on already shaky healthcare infrastructures.

By specifying how the treatment is to be administered, the fund provider creates a treatment process for HIV that is separate from the rest of the healthcare system. Having another separate process to learn and run creates new complexity and burdens on already over-burdened systems.

Then there are the staffing issues. Instead of adding new workers for the HIV programs, they usually train existing staff in HIV/AIDS treatment and give them extra money for doing so. Since workers in the AIDS programs get paid more, it draws health and administrative workers away from other (generally already under-staffed) areas.

According to the report all this strengthens the nation’s ability to treat HIV, but weakens its overall ability to treat all other health issues — which are numerous.

I think the report did a good job at documenting the problem, but I was disappointed that it did not investigate or suggest a solution. It would be easy to conclude from the study that perhaps the money should just be handed over to the local health ministry.

The reason many HIV fund providers no longer do that is because they tried that approach and found it didn’t work. Other donors who support a sector approach through ministries get so bogged down with bureaucracy and politics that in many cases nothing happened and if it did, it simply took too long.

Generally, the American donor organizations favor the approach outlined in the report, although many do actually give directly to ministries as well. This results in fast action, but as the report says, can create other obstacles, i.e. sustainability issues and shortage of workforce in other areas.

One thing the CGD paper did not mention is the effort that donors are making to shore up local healthcare infrastructures. I think it’s important to mention that most donors do realize these problems exist and are trying to improve the situation. The World Bank used a whopping 40% of its HIV money for bolstering local infrastructures, and the new PEPFAR plan includes a program to train 140,000 health care workers.

Science recently addressed many of these issues in an investigation of how HIV funding is being used titled ‘HIV/AIDS: Follow the Money.’ In the feature, they call for the whole system to be re-thought and point out that many are questioning if all this money for HIV is only made possible by sacrificing treatment for other diseases.

The article also points out that many countries with poor infrastructures miss out on funding because donors realize much of the money will go to waste if they give it to them. The major contributors will not give more money to a country if they feel that country cannot handle it.  In most countries, that maximum capacity doesn’t provide enough money to treat everyone. So simply going around local health infrastructures is clearly not the way to make universal access a reality.

HIV is a long-term problem and clearly the current way of doing things is a short-term solution.  It’s fantastic that these programs have saved so many lives. It’s a shame the only way they can achieve these results is by circumnavigating the health ministries.  The bottom line is that millions are in need right now and they cannot afford to wait for efficient health care systems to develop. But develop they must. 

It is not the donors’ responsibility, but that of the governments who run the health ministries.

AIDS slang speaks volumes

You can learn a lot about the perception of HIV by looking at the words people use to talk about it. I’ve just found this list of HIV slang from plusnews.org.  The terms come from some of the African countries hardest hit by the HIV pandemic.

The outlook for a person who contracts HIV in Africa is improving, but as these terms reveal the perception on the streets is rather bleak. Many of the slang phrases are also quite clever, like ‘Five and three’ (because eight sounds like AIDS). Let us know if you have any terms to add to the list and we’ll pass them on to plusnews.  

Angola (Portuguese)
Pisar pisar na min - Contracting HIV is like having "stepped on a landmine"
Bichinho - "Little bug" (the virus)

Kenya (Kikuyu, spoken mainly in central Kenya)
kagunyo - "The worm" (euphemism for HIV)

Nigeria (Hausa, spoken mainly in the north)
Kabari Salama aalaiku - Literally translates as "Excuse me, grave" (reference to AIDS)
Tewo Zamani - Translates as the “sickness of this generation” (another reference to AIDS)

Nigeria (Igbo, spoken mainly in the east)
Ato nai ise - "Five and three" (5 + 3 = 8, and "eight" sounds like "AIDS")
Oria Obiri na aja ocha - "Sickness that ends in death" (euphemism for AIDS)

Nigeria (Yoruba, spoken mainly in the west)
Eedi - "Curse"
Arun ti ogbogun - "Sickness without cure"

Nigeria (Pidgin, the unofficial lingua franca)
He don carry - "He carries the virus"

Nigeria (English)
HIV - He Intends Victory (acronym of HIV and a phrase popular among born-again Christians)

South Africa (IsiXhosa and IsiZulu)
Udlala ilotto - "Playing the lotto" /ubambe ilotto - "won the lotto" (said of someone suspected of being HIV positive; Lotto is the national lottery)
Unyathele icable - Contracting HIV is like "stepping on a live wire"

South Africa (English)
House in Vereeniging - (Acronym of HIV; "bought a house in Vereeniging", a town about 50km south of Johannesburg, refers to someone suspected of being HIV positive)
Driving a "Z3"/ "having three kids"/ the "three letters" - All refer to the three letters in the HIV acronym
Tracker - If you are suspected of being HIV positive people say God is tracking you, like the popular southern African service that tracks and recovers stolen vehicles

Tanzania (KiSwahili)
amesimamia msumari - "Standing on a nail"; euphemism for being skinny, or being small enough to fit on a nail's head, referring to AIDS-related weight loss
kukanyaga miwaya - Contracting HIV is like "stepping on a live wire"
mdudu - "The bug" (refers to HIV)

Uganda (English)
Slim - Euphemism for HIV/AIDS as a result of the associated weight loss; less popular since the advent of ARVs

Uganda (Luganda, spoken mainly in the central region)
Okugwa mubatemu - You have been waylaid by thugs (contracted HIV)

Zambia (Nyanja, spoken mainly in the east and the capital, Lusaka)
Kanayaka - "It has lit up" (refers to a positive reaction from an HIV test)
Ka-onde-onde - "Thing that makes you thinner and thinner" (HIV)

Zambia (Bemba, spoken mainly in the north and Lusaka)
Bamalwele ya akashishi - "Those that suffer from the germ" (HIV-positive people)
Kaleza - "Razor blade" (Refers to a person being thin as a result of AIDS-related weight loss)

Zimbabwe (Shona)
Ari pachirongwa - "He/she is on a (treatment) programme"
Akarohwa nematsoti - "He/she has been beaten by thieves"
Mukondas - Abbreviation of "mukondombera" (epidemic)
Ari kumwa mangai - "He/she is drinking mangai" (mangai is boiled corn seeds, which represent antiretroviral (ARV) drugs)
Akabatwa - "He/she was caught" (received a positive diagnosis)
Zvirwere zvemazuvano - "The current diseases" (the HIV epidemic)
Akatsika banana - "He/she has stepped on a banana and slipped" (someone who has tested positive and therefore will "fall" or die as a result)
Shuramatongo - "A bad omen for relatives"

Zimbabwe (English)
Red card - Like a football player being sent off, life is over
Go slow - Taken to mean that he/she is now progressing slowly towards death
TB2 - Refers to high rates of HIV and TB co-infection (used to denote AIDS)
RVR - Slang for ARVs, adapted from Mitsubishi's RVR sports utility vehicle
John the Baptist - When someone has TB or HIV, he/she is said to have been baptised by "John the Baptist", who has come to announce the coming of AIDS
FTT - "Failure to thrive" (adapted from the medical phrase, now used to describe HIV-positive children)
Boarding pass - Implies that HIV is a boarding pass to death
Departure lounge - An HIV-infected person is in the departure lounge awaiting death

Photo courtesy of General Idea, Toronto

A Taxi Ride in Lusaka

I don’t know about you, but I love talking to taxi drivers. More often than not they have an opinion and are willing to share it. They are a wealth of local knowledge, invaluable to a constantly inquisitive traveler like me. 

On one trip in Lusaka I was chatting to Chris, a local taxi driver. He was taking me from my hotel to the Swedish Embassy a short drive away. After the usual discussion about the fare, conversation turned rapidly to football. He gave the usual nonstop hysterical laughing fit at the suggestion QPR were obviously the greatest football team in the world and we soon settled down to further discussion about family and work. 

Once he knew I worked with HIV, he told me of family members who had passed away and the devastation the disease was causing. Now I know this will seem rude, but I always make a point of asking whether the taxi driver has had an HIV test or not and in Chris’s case it was no different. His answer was the same one every taxi driver I have ever spoken to in Africa has given. 

NO. 

The reasoning is this: “Since you cannot provide treatment for me, there is no point in me taking the test since I am going to die in a few years anyway. If I take the test and I am positive, I will lose my job, my friends and
possibly my family, and I will die a lonely poor man in a few years. However, if I don’t take the test, then I will not know, I will keep my job, my friends and my family, and will still die in a few years but not as lonely and not as poor.” Of course I always ask the question: “Aren’t you scared of spreading the disease?” Chris’s response was
typical – a shrug of the shoulders and a change of conversation back to football.