The "free by 5" campaign for universal, free antiretroviral therapy

[Cost and factors associated with the prescription of non-antiretroviral drugs among HIV-infected patients under antiretroviral therapy in a reference hospital in Morocco]

Objective

To determine the costs of non-antiretroviral drugs and to identify the factors associated with their prescription in HIV-1 patients on antiretroviral therapy in Morocco.

Methods

Retrospective study of a cohort of 264 patients living with HIV-1 who were given antiretroviral therapy in the Venerology Dermatology Department at the Mohamed V Military Training Hospital of Rabat during the period from January 1st, 2014, December 31st, 2018. The costs retained were those of the hospital pharmacy for essential drugs, otherwise they were the costs in the private pharmacies. The logistic regression model was used to analyze the factors associated with prescription.

Results

Of the 264 patients included, the male predominance was 75%. The median age of patients was 49 [41-57]. At the onset, 21.2% of patients were already in the AIDS stage. After a mean duration of 11.1 ± 6.8 months of antiretroviral therapy, 71.6% of patients received at least one prescription for a non-antiretroviral drug. Over the entire follow-up period, the mean cost per patient was 24.2 €, and the mean cost supported per patient was 22.1 €. After cotrimoxazole (30.7% of patients), the most frequently prescribed drugs were iron (29.2% of patients), antibiotics (20.8% of patients), hypolipemics (20.1% of patients) and general antimycosics (16.3% of patients). Age (RR: 1.01; 95% CI: 1.00-1.07), AIDS stage (RR: 2.15; 95% CI: 1.61-4.19), anemia (RR: 2.02; 95% CI: 2.10-5.41) and number of comorbidities (RR: 2.45; 95% CI: 2.10-5.41) were significantly associated with the prescription of non-antiretroviral drugs.

Conclusion

Our work highlights the high frequency of prescription of non-antiretroviral drugs in patients living with HIV in Morocco; especially those who are older, anemic at the onset and those who are already at the AIDS stage.

Planning and sustaining HIV response in the countries of the "risky middle"

This paper focusses on high-HIV middle-income countries termed the "risky middle", i.e. characterised by a typology based on HIV burden and gross national income (GNI), according to which seven countries - Lesotho, Eswatini, Kenya, Zimbabwe, Tanzania, Namibia and Zambia - are identified. There is particular concern for "people left behind", the factors determining a country's ability to mobilise resources in the context of multiple development needs - including economic disparities; the political economy of fiscal decision-making; levels of health investment; health and community systems; political will; and currency fluctuations. While donors will support lower-income countries and higher-income countries can compensate from domestic resources, there is a risk that some high-burden, lower middle-income countries will be unable to sustain a response. Continued growth means that there are countries transitioning to higher World Bank income classification - an important criterion for allocating development assistance for health. Our concern is that countries may face external funding reduction once their income category improves, and those in the risky middle will be unable to compensate from domestic resources. We conclude, with guidance from UNAIDS, the international community should step up support for "risky middle" countries. In addition these countries need to recognise the threat and develop measures to counter it, including improved accountability. Funding declines should be reversed through funding benchmarks that relate to both GDP and HIV prevalence. Finally, risky middle countries could constitute themselves as a special interest group, to protect their HIV funding and AIDS response.

New and Re-Emerging Infectious Diseases in Sub-Saharan Africa

Over the past 30 years, Africa has achieved significant health gains. Life expectancy has risen while infant, child, and maternal mortality have declined. Despite these improvements, the continent still faces serious challenges from infectious diseases. The chapter covers HIV and AIDS and other epidemics in sub-Saharan Africa. It addresses the origins, evolution, mortality, morbidity, and socio-economic impacts of the epidemics, as well as the policies and programs put in place to combat them. The chapter concludes with a review of the funding and the sustainability of such financial efforts.

Access to antiretroviral treatment in developing countries: Which financing strategies are possible?

BACKGROUND

In low- and middle-income countries, access to combination antiretroviral therapy for all people living with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in need of treatment is a major public health challenge. The objective of this paper was to provide an overview of the different financing modalities of HIV/AIDS care at the microeconomic level and an analysis of their advantages and limitations.

METHODS

A review of the published literature using mainly the Medline and Science Direct databases for the 1990-2008 period in English and French made it possible to explore different financing strategies for the access to combination antiretroviral therapy using as case studies specific countries from different regions: Ivory Coast, Uganda, Senegal, and Rwanda for sub-Saharan Africa, Brazil and Haiti in the Latin America/Caribbean region, and Thailand for Asia.

RESULTS

In these settings, direct payment through user fees is the most frequent financing mechanism in place for HIV/AIDS care and treatment, including combination antiretroviral therapy. Nevertheless, other mechanisms are being implemented to improve access to treatment such as community-based health insurance schemes with free care for the poor and vulnerable households and public-private partnerships.

CONCLUSION

The type of financing strategy for HIV/AIDS care and treatment depends on the context. As direct payment through user fees limits access to care and does not enable program sustainability, national and donor agencies are introducing alternative strategies such as community financing systems (mutual health organizations, micro insurance, community health funds) and public-private partnerships. Finally, access to combination antiretroviral therapy has improved in resource-limited settings; however, there is a need to introduce alternative financial mechanisms to ensure long-term universal and equitable access to treatment and care, including combination antiretroviral therapy.