Mit Philips on doublespeak in Vienna

MSF's Dr Mit PhilipsThe high point of the summer, for those involved in HIV-AIDS, was the Vienna AIDS conference – a perfect mix of evidence, policies, and politics. While some of the scientific papers presented were fascinating, what interested me most was the platform the conference provided for different stakeholders to come together and put the tensions that exist between them squarely on the table.

The focus of the conference had been billed as human rights, and I had expected there would be a lot of attention on discriminatory attitudes towards HIV patients in eastern Europe. But in the event, what dominated the discussions was the subject on everyone’s minds: the all-important HIV backlash – in particular the flatlining of HIV funding, the retreat from ART scale-up and the move away from an emergency approach in treating people with HIV, despite the fact that it is still a major global crisis. The right to lifesaving treatment for more than the lucky few is well and truly back on the agenda.

Discussions crystallised around the implementation of the World Health Organization’s new guidelines, specifically the recommendation to start people early on treatment, at a CD4 count of 350. In the US and Europe, this has been standard practice for some time – and as a consequence, HIV has been reduced to a chronic illness, rarely acutely life-threatening in the west. But in Africa, people are not receiving treatment until their CD4 count falls below 200, when the disease has progressed further and their immune systems are significantly weaker – as a result, those starting treatment face slimmer chances of survival. And the many patients who are told to wait for their CD4 count to drop contribute to the large numbers of people with AIDS who are still dying.

Eric Goosby, the US Global AIDS Coordinator, wriggled out of pledging his country’s support for the WHO guidelines, and tried to cover this reluctance with political discourse. We need to accept, said Goosby, that we just don’t have the resources to start treating people earlier. This was echoed by other delegates, who talked about the lack of resources as if they were a law of nature, rather than the consequence of deliberate choices in donor countries. We need to distinguish between facts and convenient excuses.

If we accept what the politicians say – that the resources are just not available – then the concept of rationing is the only option left. Although everyone accepts the scientific validity of the new WHO guidelines, the benefits linked to them are already being rationed, and the proven standard of care, applied in rich countries, is proving to be out of reach in low-resource settings.

Goosby argued that we should only treat the people with a CD4 count below 200, as they are the ones at highest risk of dying and transmitting the virus. He went so far as to suggest that it is our human and medical obligation to focus on these patients. It surprised me that no one countered this by pointing out that the best way to prevent a CD4 count from dropping in the first place is to treat people earlier; starting at a count of around 350 would reduce that dangerous phase for many people. The reason that people are at such high risk of dying is that we haven’t been able to apply the guidelines and treat them when they need it. Goosby’s argument is populist but not fact based – you could say it camouflages the scientific evidence.

I would almost have preferred Goosby just to come out with it, bluntly: that the US is choosing not to pay for the extra costs implied by the WHO guidelines. This would be less damaging than shedding doubt on the potential benefits of early treatment, and advising African governments against applying the evidence. Early treatment would not only change patients’ lives, it would also have major implications for health services as a whole. Without early treatment, the numbers of patients who are severely ill and suffering from complications will make task-shifting and decentralised care impossible. Not treating people early will weigh heavily on the costs of service delivery.

Bill Clinton was another one who indulged in doublespeak. When he talked about “efficiency,” he wasn’t refering to getting better results for the costs put in; he was talking about simple cost-cutting measures – a dangerous re-definition, in my view, as you risk cutting the benefits too. Treatment for HIV patients has to be effective, and  the objectives cannot be compromised. There are many ongoing efforts to make the strategy of rolling out treatment more efficient, but this implies increasing benefits for more people. Starting fewer people on antiretrovirals, or starting them later, will sabotage the treatment, not improve its efficiency.

This was my major frustration: here we were, at an international AIDS conference, being lectured about resources and efficiency at the expense of proven scientific facts. Are we really back to accepting there is one science for those with means and another for those without? 

However, frustrations aside, it was great to see the drive and innovation that is going on in the field of HIV. It is still a small miracle that so many different stakeholders have mobilised around the issue. In any one session you could see anthropologists, sociologists, patients, scientists, health workers, governments and NGOs all interacting, bringing an energy and breadth of vision to the debate – something that other health priorities could really benefit from. If the world takes it focus off HIV, we risk losing all the richness of that interaction, and losing the possibility of expanding the mobilisation against poor health for the poor.

Dr Mit Philips is Health Policy Analyst for Médecins Sans Frontières.