Why are so many going without life-saving HIV treatment?

Seven million people living with HIV – more than the population of Libya, Denmark or Costa Rica – are without treatment and most likely to be poor, black or migrants, writes Rowenna Davis

Going without existing HIV treatments means more personal suffering and leaves others at risk of infection. So why do so many go without?

The first problem is that many of the untreated seven million don’t even know they are HIV-positive. Free, universally accessible testing is taken for granted in the West, but that is not a luxury everywhere. Even where it is free, the fear that, for many, comes with testing and the consequences that might follow a positive diagnosis holds people back.

“The majority of HIV transmissions happen from people who don’t even know they are infected,” says Anja Teltschik, a senior adviser at the International HIV/Aids Alliance. “And as long as people do not know that they are living with the virus, they have no access to life-saving treatment that can also reduce the risk of infecting others.”

In poorer and migrant communities, stigma can go much deeper. HIV can be seen as a punishment from God for taboo behavior, be it homosexual sex, drug taking or multiple sexual partners. In areas of Eastern Europe, for example, authorities deny treatment to drug users, who are considered unworthy of medical resources. Patient confidentiality is not guaranteed across the globe, and individuals can find themselves shunned by family, friends and employers.

Untreated patients come from poorer countries, where infrastructure is poor, health services are overburdened and drugs are expensive

Resources are the next hurdle. The bulk of untreated patients come from poorer countries, where infrastructure is poor, health services are overburdened and drug patents are expensive. But some African leaders have shown that dedicated governments can achieve results. Extra resources in Botswana mean that 93 per cent of people now have access to the antiretrovirals they need. Malawi has made great strides by adopting a plan called “B+”, which offers mothers immediate life-long access to treatment at the same time as preventing transmission of the virus to their children.

Unfortunately, not every country has made HIV a priority, and corruption and poor governance can also get in the way. Although Africa is often associated with some of the worst conditions, it has received massive international support and funding. Eastern Europe, on the other hand, has not had the same treatment and has suffered outside of the spotlight. Ms Teltschik, who has lived and worked in the region, says the difference is palpable.

But she says material resources aren’t the only issue at stake. “Treatment doesn’t work without community infrastructure. You need peer-to-peer support and counselling to make sure people stick with their treatment plan. In the past, governments have been quick to invest in healthcare, but they haven’t thought about the community support.”

Rising expectations and new treatments mean that even countries that are working hard to combat HIV can feel like they are falling behind. Treatment as prevention (TasP) is the term used to describe the provision of antiretroviral drugs to people living with HIV to prevent sexual HIV transmission, in addition to providing the person with life-saving treatment. Pre-exposure prophylaxis (PrEP) takes this one step further by giving the drugs to a person who does not have HIV, purely to prevent them from acquiring HIV from an infected partner. Although evidence says PrEP works, the practice is still controversial.

“This approach does raise serious and difficult ethical questions,” says Sir Nick Partridge, chief executive of the Terrence Higgins Trust. “Is it right to fund drugs for people who don’t have HIV, when there are many who are already diagnosed who can’t afford treatment?”

With 7,000 new HIV infections a day across the globe, health professionals say that it is still better to focus resources on prevention as much as treatment. Although new high-tech solutions can raise excitement, they are not necessarily the most cost-effective. In fact, experts say that good old-fashioned condom use and sex education may be the best way to get that seven-million figure down. As Sir Nick puts it: “It’s so easy to get bored with campaigns because they are politically sensitive, but we’ve got to maintain that focus… let’s do what we know works.”