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What Diabetes can learn from AIDS

Medicus Mundi Bulletin, No 115, 2010 - HIV/Aids has become more and more a disease which is characterised by factors, which can be compared with chronic diseases. Many experiences in the treatment of people living with Aids can be used for patients of non-communicable diseases.

HIV has started as a devastating, acute infection in the 1990ies, destroying millions of lives within years. It has hit Africa as a silent Tsunami, a gigantic wave rubbing out generations, turning children into orphans and pressuring health system beyond limits. The impact of the disease goes far beyond health, with social, cultural, economic and political consequences. In many Sub Saharan countries, Aids has decreased life expectancy by at least 10 years (often from 45 to 35 years). It is still the leading cause of mortality in both men and women in Africa. Currently, ca. 33 Mio people worldwide are infected, 70% of them in Sub Sahara Africa, with 2,5 Mio new infections and 2,1 Mio Aids deaths occurring every year.

Aids has led to widespread human suffering. But it has generated a global coalition of people determined to prevent and treat the disease, and to care for the sick. Grassroots organizations, philanthropists, policy makers, research institutes, private sector companies, patient groups and funding bodies: They all have joined forces to sustain the momentum. As a consequence, funding has increased ten fold since the year 2000 (reaching 10bn USD in 2007), new antiretroviral drugs have been licensed, treatment prices have been falling, technologies have been developed and new global institutions have been created. The UN has set clear and measurable targets. This global determination to act on Aids has led to unexpected results, with currently 4 Mio people on life saving ARV’s and 45% infected mothers accessing treatment to prevent transmission to the baby. The massive treatment roll-out has transformed patient’s lives, health systems, policy maker’s minds and the disease itself, which has turned from an acute illness into a chronic condition, necessitating life long treatment. And despite certain specificities such as its association with stigma, sexual transmission, alternation between phases of well being and acute illness, and the need for laboratory support, HIV today shares most of its features with other chronic diseases.

The management of Aids as chronic condition in Africa is highly successful, with positive consequences both at individual and population level: The current life expectancy of HIV positives in South Africa after the first year of treatment is almost as high as in the general population. The number of Aids deaths has begun to decline on global scale. ART has led to decreased population level adult, infant and under-five mortality. And there is growing evidence that ART has an important causal link to reduced HIV incidence and prevalence.

Why is the antiretroviral roll-out such a success story? And what lessons can be learnt for other chronic diseases?

SolidarMed as Swiss organization for health in Africa implements a region wide HIV treatment and prevention program in four Sub-Saharan countries since the year 2004, in nine hospitals and 39 health centres. Together with its local partners, SolidarMed cares for more than 20’000 HIV positive patients and treats more than 6’000 people with antiretroviral drugs.

The following eight key lessons learnt, relevant for chronic diseases, can be drawn from this experience:

1) Human resources for health

2) Adherence and Retention

3) Interdisciplinary care teams and chronic disease units

4) Infrastructure, logistics, communication and technology

5) Prevention and Treatment

6) Measure, measure, measure

7) Global coalitions and realistic judgement of interests

8) Diagonal, public health approach

The biggest lesson learnt from HIV is the feasibility and success of the WHO-led public health treatment approach, offering simplified and evidence based treatment algorithms for a condition which is complex and difficult to manage. This public health approach has enabled the current treatment of 4 Mio people. The future challenge will be to keep them under treatment, to scale up further, and to provide treatment of better quality. (Jochen Ehmer, in Bulletin von Medicus Mundi Schweiz Nr. 115, Februar 2010)

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