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CHALLENGES OF HIV TREATMENT IN LAOS
In May 2005, the head of mission for Médecins Sans Frontières (MSF) Switzerland in Laos, Thierry Dumont, addressed the Annual General Meeting of MSF Australia in Sydney. The following interview follows his presentation titled "Fighting AIDS in Laos – Constraints and Limits" which highlighted the various challenges that lay ahead in the treatment of HIV/AIDS and its expansion in Laos. You can also watch the advocacy video developed for Laotian Television which is aimed at reducing the stigmatisation experienced by those affected by HIV whilst raising awareness about the availability of HIV/AIDs treatment. MSF started the first ever HIV/AIDS treatment project to be implemented in the country in 2001. How many people are infected with HIV in Laos? Nobody really knows as there has never been testing throughout the country, but the official prevalence rate at the national level is 0.1%, and in Savannakhet Province [where MSF is present] it is about 1% - ten times more than the national rate. Recently, a survey done by the National Aids Centre (although not officially released yet) among prostitutes in the major cities of Laos, shows that the average prevalence is increasing from 0.9% to 2.5%. This means that the prevention efforts are not 100% effective and major changes in prevention policy must be taken rapidly. What activities are involved in the treatment of HIV?
We are now caring for 300 patients in Savannakhet Province since we began in July 2001, with 220 of them receiving Highly Active Antiretroviral Treatment (HAART). The care we provide means providing Voluntary Counselling and Testing (VCT); treating Opportunistic Infections (OI) and giving access to ARV treatment. We also have a laboratory which is a very important and quite costly part of the project because we must test all patients and monitor the number of their CD4 cells (otherwise known as CD4 count which indicates the level of immune suppression*). CD4 count is very important for assessing the efficacy of the treatment and also for taking the decision to start a patient on ARV treatment. * Monitoring CD4 (the white blood cell targeted by HIV) is also difficult, since most of the commercially available CD4 count machines are not adapted for use in young children. What are the greatest obstacles to HIV treatment in Laos? Poor knowledge is the most important one and then as a consequence, education, stigma and political commitment. Just before we first started the project in 2001 the position of the government was that ‘there is no HIV in Laos’ – and changing that perception has been the first challenge. Today the perception is different and a little more realistic however there is still some resistance. The virus is definitely inside Laos and officially recognised however we are not really sure that everybody believes that access to treatment is necessary. Despite this situation we have successfully lobbied for the inclusion of the principle of ‘access to treatment’ in the National HIV Policy for 2006-2010.
Another thing to consider is the fact that the HIV epidemic started in Asia ten years later than it did in Europe, and then it started in Laos about 10 years after the rest of Asia, so when you see how long it took for European or North American authorities and the public to be committed to treatment, and the fact that in Laos they have literally just discovered it (first case of HIV in Laos was recorded in 1990), then it will take some time for people to come around. I also believe that this commitment for the provision of treatment is hampered because some people actually believe that it’s better not to give treatment, because if people have access to treatment then they won’t be scared of getting infected. But you can’t support this kind of policy – it’s a ‘non-policy’, however with education and further lobbying we will change this. Also with lack of knowledge and education comes stigmatisation, which is another challenge, but we have found that when people come to the hospital to receive treatment and return to their village when they are better and physically able to start working again, there is no stigmatisation anymore. What is the potential for spread of the disease in Laos? Honestly I don’t know if it’s spreading fast or not but I am sure they will have problems. As far as we know the virus has already spread to rural areas and we can already see this in Savannakhet Province because while we are caring and treating for 300 patients, we know that there are more people out there. I predict that if we start another project in Vientiane then we will have at least 300 patients very quickly because we already know 100 of them. At the moment in Savannakhet we have about 15-20 new patients every month and that is a steady figure – that means if we have 300 now, then by the end of the year we’ll have 400 patients and we don’t know where it will stop because we don’t know the real rate of infection. But there are several cultural factors that predispose the Lao population to this disease – in a country of six million people the sexual behaviour is really high risk; meaning they are not always using condoms if at all and many have bi-sexual relationships or encounters. Homosexual behaviour amongst heterosexual males is not uncommon in Laos nor is it a big deal. There is also the patronage of “service woman” or as we call prostitutes, which also means high-risk behaviour when it comes to HIV. There are limited resources in the world for treating AIDS in resource-poor countries, why in Laos when there are far-worse affected countries in Africa?
I believe we can really help in Laos. We have already helped by: *The Global Fund to Fight AIDS, TB and Malaria was created to dramatically
increase resources to fight three of the world’s most devastating
diseases, and to direct those resources to areas of greatest need. As
a financing mechanism, the Global Fund works closely with other multilateral
and bilateral organisations involved in health and development issues
that newly funded programs are coordinated with existing ones. In many
cases, these partners participate in local Country Coordinating mechanisms,
providing technical assistance during the development of proposals and
implementation of programs. If there is Global Fund support in the future, how will MSF support the government? Global Fund support is part of the sustainability of our HIV project in Laos. We plan to close our project in Savannakhet in 2008; by this date the Virology Unit at Savannakhet Hospital will have the capacity to work without MSF’s help; and with drugs and laboratory items purchased with GF money. Until this date MSF will go on training people; will use the drugs of the GF if we have them before 2008 (hopefully in 2006) and we will go on with scaling up treatment and technical support. So does this mean that MSF will use drugs procured via GF funding and then manage/supervise the National AIDS program in relation to treatment? Yes, we’ll use the drugs procured via GF funding, but we are not supposed to manage or supervise any national program. Along with the World Health Organisation (WHO) we can help to build such a program. What is the potential for this GF funding? What would be the objectives…scale-up of treatment?
It depends on the quality of the proposal of course, but the fact that MSF is working in a country is already a good thing for potential funding from the Global Fund, however we must not be unreasonable because it is easy to say we can scale-up treatment to X number of patients in 12 months etc, however it is much more difficult in reality. Some proposals to the GF were simply refused last year because the goals set were not realistic at all, and the Global Fund has the ability to just say “yes” or “no” to be able to release funds rapidly so it is very important that proposals and goals for scale-up are reasonable. To be very short, the main goal for MSF is to provide free access to treatment to those who need it. To achieve this main goal there will have to be training for medical staff in Laos and outside of Laos; training for policy makers; supply of equipment, drugs, laboratory items and construction of facilities etc. Until now the GF grants for Laos have all been for prevention programs, and this was the entry point for treatment in the national policy and the Global Fund was waiting for it. Next, implementation will be the word.
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proving it’s
possible to treat Lao people infected with HIV in Laos with ARV, thanks
to the Savannakhet pilot project;