The number of people in the developing world who are receiving anti-HIV drugs jumped 60 percent in the last six months of 2004, to 700,000. That is more than the number of people on combination therapy in the U.S.
In December 2003 the World Health Organization ( WHO ) announced the '3 X 5' campaign with the goal of having three million people in the developing world on anti-HIV therapy by the end of 2005. Even its most fervent supporters acknowledged that it was an ambitious goal that would be very difficult to meet.
This latest updated treatment figure, contained in a WHO report released on Jan. 26, show both the tremendous progress being made and the distance left to travel. Only one in eight persons in the developing world who would benefit from therapy are receiving it.
'A bigger commitment from South Africa, Nigeria, and India is crucial if the developing world is to meet this year's treatment goals,' said Jim Yong Kim, the head of WHO's HIV/AIDS programs.
One thing that can help speed that process along is greater use of less expensive generic drugs. The FDA approved the first generic combination therapy for HIV on January 25. However, it is licensed only for use in the developing world.
Aspen Pharmacare of South Africa will manufacture both an AZT/3TC combination pill and a nevirapine pill at adult strength formulations under licensing agreements with the pharmaceutical companies that developed the drugs. The licenses only allow for sales in the developing world and not in the U.S. or Europe.
FDA approval makes the drugs eligible for purchase under the President's Emergency Plan for AIDS Relief ( PEPFAR ) , the Bush administration's international AIDS initiative. The generic drugs will cost a third to a half the price of branded drugs and will allow more people to receive treatment.
Other generic anti-HIV drugs are manufactured in India and have been used in some countries in Africa. However, there has been some question as to the documentation of their equivalency to the branded products that they copy. They have not yet been approved by the FDA and do not qualify for purchase under PEPFAR.
The Bush administration will propose spending $3.2 billion for PEPFAR in the fiscal year 2006 budget, unnamed administration and congressional sources told Reuters. Last year it proposed $2.8 billion in international spending and Congress upped that to $2.9 billion. Domestic spending for AIDS has remained essentially flat.
Administration critics contend that the U.S. should be spending roughly double that amount internationally. But they acknowledge little sympathy in Congress for such massive increases while other programs are receiving little or no increase.
Malaria remains a huge problem in much of the tropical developing world where it is transmitted by mosquitoes. A report in the Jan. 15 edition of the British medical journal Lancet demonstrates that the HIV viral load of people nearly doubles when they become infected with malaria. This is likely because of the additional challenges of a dual infection to the immune system.
Other research has shown that the likelihood of transmitting HIV to an uninfected person increases proportionally with their viral load. Coinfections with other diseases such as malaria, tuberculosis, and sexually transmitted diseases—often untreated or under treated because of limited access to health care—helps to explain the higher incidence of infection and faster progression of HIV disease that is seen in much of the developing world.,
CIRCUMCISION
Another factor affecting the rates of transmission is circumcision, or the lack of it. A study published in the Feb. 15 edition of the Journal of Infectious Disease, and available early online, found that among presumably heterosexual Kenyan men having multiple sexual partners, the uncircumcised had more than twice the risk of acquiring HIV than did those who were circumcised.
The study was conducted between 1993 and 1997 among 745 male truck drivers in Kenya. All were initially HIV-negative. Periodically throughout the trial they were asked about the number of sexual encounters with wives, casual partners, and prostitutes and were screened and treated for sexually transmitted infections as well as HIV.
Statistical analysis showed that the uncircumcised men became infected once every 80 times they had sex, while the circumcised men became infected once every 200 times.
Earlier studies had pointed to similar findings but there was a question as to whether cultural practices, such as those associated with being Muslim, were a factor in helping to explain the different rates of infection. Subgroup analysis of this study found that was not the case. Even when controlling for such factors, the probabilities of becoming infected with HIV remained the same.
The likely explanation is that the head of an uncircumcised penis remains a softer mucus membrane that HIV can more easily enter, while the head of a more exposed circumcised penis develops a tougher layer of skin that is more resistant to viral entry.
Three large scale trials currently are underway in Africa to determine if voluntary adult circumcision offers similar protection. The outcome of those trials should be known in one to three years.
