Global lessons from AIDS


A decade after the global AIDS response began in earnest, it’s worth asking whether the lessons learned will be sustained over time and used to avoid past mistakes when tackling new challenges.

One such challenge is chronic hepatitis C infection, which afflicts an estimated 170 million people worldwide. Since its discovery 25 years ago, hepatitis C has become the leading indication for liver transplant in the United States and a common cause of liver failure around the world. For some, however, it is about to become eminently curable.

When I trained as an infectious disease physician in the mid-1990s, I traveled frequently between Boston’s teaching hospitals and rural Haiti. AIDS had become a leading cause of death in both places but was rapidly declining in Boston while soaring in Haiti, as it was across Africa.

This divergence was thrown into relief at a 1996 AIDS conference where researchers presented data showing that combination antiretroviral therapy could transform HIV infection from a death sentence into a manageable chronic disease. The conference’s theme that year was “One World, One Hope.” A coalition of activists, noting the $15,000 annual cost of the lifesaving drugs and the lack of an international plan for ensuring access among those living in poverty, held up their own signs reading “One World, No Hope.”

By 2000, more than 6 million people were dying in poor countries each year from HIV, tuberculosis and malaria — diseases for which effective therapeutics were available to those who could afford them. Here was a failure not of science but of delivery.

Thankfully, and in no small part because of the relentless efforts of AIDS activists, an abiding cynicism about the limits of an international response to these pandemics gave way to an unprecedented “delivery decade.” This was inaugurated in the early 2000s with the U.S. President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

As I recounted in the New England Journal of Medicine in December, linking this funding to effective delivery mechanisms had profound effects in some of the world’s poorest and most disrupted places. By the end of 2012, almost 10 million patients in low- and middle-income countries were on antiretroviral therapy. In Haiti and Rwanda, AIDS-related mortality rates fell more sharply than in the United States after its introduction of antiretroviral therapy in the mid-1990s.

Despite such progress, much remains to be done. Nearly half of all people living with HIV who need treatment still don’t receive it. But the coupling of an equity plan with a commitment to building effective delivery systems surely ranks among the most important achievements in the history of medicine and public health.

Today, the world faces a “1996 moment” in the fight against hepatitis C.

As in 1996, highly effective new therapies are coming online. Regimens containing the new polymerase inhibitor sofosbuvir, in particular, have the potential to cure more than 90 percent of patients with common strains of the virus after just 12 to 24 weeks of once-daily pills. But is there a plan that can link funding to delivery for those living in poverty?

Sofosbuvir’s initial price has been set at $80,000 to $90,000 per 12-week course — about $1,000 per pill. Like those infected with HIV, 90 percent of hepatitis C patients live in low- and middle-income countries; most would not earn $80,000 over the course of two lifetimes.

In the face of such numbers, it is tempting to give in to pessimism. “Poor countries could never afford these prices; the demand simply isn’t there,” some say. But when the share of those infected with hepatitis C reaches 1 in 40 people alive today, claims of weak demand are not credible. Such language is often code for ability to pay, not actual burden of disease. In many years practicing medicine, I have yet to meet a patient — rich or poor — with a treatable disease who doesn’t want to get better.

Drug prices are not immutable, and price is not the same as cost. Pharmacologists with Liverpool University recently analyzed manufacturing processes for new hepatitis C regimens and concluded that they could be sold at profit in poor countries for less than $500 per course. A recent pledge by Gilead, the developer of sofosbuvir, to work with generic pharmaceutical firms in India is a promising start, but it is just a start.

Precipitous drops in price are not unprecedented; in the delivery decade, innovative partnerships through financing mechanisms such as UNITAID led to declines of as much as 99 percent in the effective price of antiretroviral therapy for the world’s poorest.

Smart investments in accurate diagnosis and in effective therapy for hepatitis C could save millions of lives in the coming years, radically cut transmission and pave the way toward eradication of the virus. Or, we could choose to ignore the lessons of the AIDS response and stand by as outcomes improve solely among the fortunate few who enjoy ready access to the fruits of modern medicine. Divergence of outcomes occurs within nations and across them; they grow whenever innovation is not coupled with implementation among the most vulnerable.

But we live in one world. As infectious pathogens such as HIV and hepatitis remind us, our hopes are tied together more closely than we might imagine.

- - -

Paul Farmer co-founded Partners in Health. He is a professor at Harvard University and an infectious disease physician with Brigham and Women’s Hospital in Boston.

Special To The Washington Post

Read more From Our Inbox stories from the Miami Herald

  • I studied engineering, not English. I still can’t find a job.

    When I graduated from Penn State a year ago, I thought I was perfectly prepared to succeed in the business world. I’d worked hard, graduated at the top of my class in computer science and managed to acquire lots of experience with the sorts of industry software that I was sure hiring managers were looking for. I’d even chosen a STEM degree, which — according to just about everyone — is the smartest choice to plan for the future (eight out of the 10 fastest growing job occupations in the United States are STEM jobs).

  • The Beatles’ cry of freedom: ‘Money,’ 50 years later

    In early 1964, a friend called me up and asked if I wanted to hear the new Beatles album, With the Beatles. It had come out in Britain a couple of months before, but no one I knew had heard it, or for that matter heard of it. My friend’s father, an airplane pilot, had brought it back. It was just days after the Beatles’ first appearance on The Ed Sullivan Show.

  • It helps to have a hospital room with a view

    Hospitals are, by their nature, scary and depressing places. But they don’t have to be ugly as well — and there’s ample evidence that aesthetics matter to patient health.

Miami Herald

Join the

The Miami Herald is pleased to provide this opportunity to share information, experiences and observations about what's in the news. Some of the comments may be reprinted elsewhere on the site or in the newspaper. We encourage lively, open debate on the issues of the day, and ask that you refrain from profanity, hate speech, personal comments and remarks that are off point. Thank you for taking the time to offer your thoughts.

The Miami Herald uses Facebook's commenting system. You need to log in with a Facebook account in order to comment. If you have questions about commenting with your Facebook account, click here.

Have a news tip? You can send it anonymously. Click here to send us your tip - or - consider joining the Public Insight Network and become a source for The Miami Herald and el Nuevo Herald.

Hide Comments

This affects comments on all stories.

Cancel OK

  • Marketplace

Today's Circulars

  • Quick Job Search

Enter Keyword(s) Enter City Select a State Select a Category