Friday, July 16, 2010

Why is adopting "best practices" considered "radical"?

Dear Colleagues

The recent article in IRIN PlusNews has the following caption for one of the web article images: "Expanded treatment could save lives and money in the long run". The article then goes on to describe the radical idea that simpler more cost effective approaches should be adopted ... to which my knee-jerk thought is "as opposed to the complicated costly approaches that are favored by many health experts and the international community including organizations like USAID and the Gates Foundation." The is the URL of the IRIN article with the text copied below.

But the article really is not about a cost effective approach with any useful information about this ... but is really part of a pitch for more money so that cost does not get in the way of WHAT?

According to the article, the five pillars of the new best practice are:
  • Creating a better pill and diagnostics
  • Treatment as prevention
  • Stop cost being an obstacle
  • Improve uptake of HIV testing and linkage to care
  • Strengthen community mobilization
Note the item "stop cost being an obstacle"!

Experience shows that expenses increase to consume the available money ... the experts in global health and the official relief and development assistance (ORDA) community are good at this business model ... but they are less good at rethinking what can be done with the money so that there is perhaps 10 times as much benefit delivered to those in need.

There is the item "strengthen community mobilization" and that is good ... but what I do not like about the community approach is the widespread expectation that community work by local people should be unpaid while all the people in the management of NGOs and ORDA institutions are paid very good salaries and many get wonderful pensions, travel allowances and all the rest. It would be good to have a database of the top salaries in the NGO and ORDA field to get an idea of where a lot of the money goes ... and then get a table of the per worker remuneration paid to community health workers in several thousand typical communities.

There are a lot of people in need of healthcare. Why is it that so few people can afford health care? Two reasons (1) healthcare has become clever but very expensive and (2) the vast bulk of the world's people are not very well remunerated. Both these reasons should be addressed in a serious way ... not by doing a study or holding a conference but by getting some practical changes in place and getting metrics to hold peoples' fee to the fire ... accountability!


GLOBAL: A radical new UNAIDS treatment strategy

JOHANNESBURG, 16 July 2010 (PlusNews) - UNAIDS has launched a simpler, more cost-effective approach to HIV treatment, aimed at simultaneously achieving two holy grails of the AIDS response: drastic reductions in AIDS-related deaths and new HIV infections.

The approach, dubbed "Treatment 2.0", aims to drastically scale up testing and treatment using current best practices and future innovations in antiretroviral (ARV) drugs and diagnostics. The prevention benefits of extending treatment to all those in need of it are based on mounting evidence that people on ARV treatment are much less likely to transmit the virus.

UNAIDS estimates that successful implementation of Treatment 2.0 could avert 10 million deaths by 2025, and reduce new infections by one-third.

A report on the new strategy has been released ahead of the International AIDS Conference, starting on 18 July in Vienna, where one of the hot topics will be why most countries will fail to meet the goals of universal access to HIV prevention, treatment and care by the December 2010 deadline.

Worrying indications that international financial support for the AIDS response is flagging will also be debated, but UNAIDS director Michel Sidibe is pitching the Treatment 2.0 approach as offering a potential solution to both concerns.

"For countries to reach their universal access targets and commitments, we must reshape the AIDS response," he said in a statement. "Through innovation we can bring down costs, so investments can reach more people."

Better drugs

Treatment 2.0 calls for the creation of "better" HIV drugs that would be less toxic, combine multiple ARVs into one pill, and be more tolerant of treatment interruptions, as well as quicker and cheaper diagnostic tools.

The current generation of ARVs have far fewer side effects than those of a decade ago, and some are available in fixed-dose combinations, but poor adherence quickly leads to the development of drug resistance and the need to switch to more expensive second-line medicines.

Second-line ARVs also incur a number of non-drug related costs, like laboratory monitoring and clinic visits, which are often enough to push treatment out of reach, but Treatment 2.0 urges all involved in fighting HIV/AIDS to "Stop cost being an obstacle".

Bernhard Schwartlander, Director of the Evidence, Strategy and Results Department at UNAIDS, told IRIN/PlusNews that short-term investments in developing and rolling out better ARVs could radically reduce non-drug related costs in the mid- and long-term.

A smart investment

Starting patients on treatment earlier is integral to the successful implementation of Treatment 2.0, and is in line with the latest guidelines from the World Health Organization.

Earlier treatment would require an initial increase in funding, but UNAIDS argues that the reduced need for hospitalization and treatment of opportunistic illnesses, as well as the potential to avert countless new infections, would eventually save money.

"We are living in a very resource-constrained situation," said Schwartlander, admitting that it would be difficult to convince donors and governments to increase AIDS funding in the current economic climate. "But what we see is that thinking is more and more shifting to seeing treatment as a very smart investment."

Treatment 2.0 also incorporates various strategies for simplifying and improving HIV treatment that already have a proven track record, including the use of local, community-based organizations to deliver HIV services to hard-to-reach but high-risk populations, such as injecting drug users and sex workers.

Organizations like The AIDS Support Organization (TASO) in Uganda, and the Treatment Action Campaign (TAC) in South Africa, are cited as examples of the successful use of community-based approaches to mobilize people infected and affected by HIV to become advocates, educators and service providers.

UNAIDS consulted extensively in drafting Treatment 2.0 and Schwartlander is optimistic that its positive, can-do approach will motivate the various sectors of the AIDS community that have tended to operate "in silos and sporadically" to work together to overcome the many obstacles to its implementation.

"So far the response has been very positive," he said. "It may be a way to re-inspire the major donors and the countries themselves."
The five pillars of Treatment 2.0
Creating a better pill and diagnostics
Treatment as prevention
Stop cost being an obstacle
Improve uptake of HIV testing and linkage to care
Strengthen community mobilization
Source: UNAIDS

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