> N° 143 / November 2006 / Médecins Sans Frontières internal newsletter www.msf.fr DOSSIER PANDEMIC DESPERATELY SEEKING SOLUTIONS - Inventing as we go along P2 - The Ugandan model: reportage P4 - Arua Meeting: discussions between AIDS 3 heads of mission P6 - Prevention of mother-to-child transmission P10 Pandemic - Interview with Professor Win Van Damme of the Institute desperately of Tropical Medicine P12 - MSF treatment of Aids patients seeking > Map P14 MISSIONS solutions - Sri Lanka: MSF withdraws from the Jaffna Peninsula P16 - Southern Sudan: what role is there for NGOs in a region undergoing reconstruction ? P18 DEBATES © Julie Rémy - May 2006 - Darfur : Humanitarian aid held > Malawi hostage P20 - Somalia : Should MSF open a programme ? P22 INFOS - Watch and read - Seventh volume of the “MSF Speaking out” collection P24 AIDS DOSSIER Inventing as we Pandemic desperately MSF/November 2006/Translated by Alison Quayle seeking solutions “To treat as many of the AIDS patients who come to us as we possibly can.” This is the objective of our HIV/AIDS programmes, especially in Africa. We must now turn our efforts towards covering the needs as widely as possible. It is a very unusual concept for Médecins Sans Frontières to say, and above all a radical step forward, five years on from the start of our first AIDS programmes. Number 143 WE CAN ALWAYS DO BETTER In late 2000 and early 2001, MSF’s For MSF, two years on from the first trouble getting enough funding to objective was to start treating AIDS patients, the objective was no longer match the needs, and national Although we procrastinated at length patients with antiretroviral (ARV) starting individual treatment, but programmes were taking a long time before starting, MSF is among the therapy, and to show that it was moving on to “scaling up”, increasing to set up, or were even non-existant. ‘pioneers’ treating Aids in developing perfectly possible to treat poor the number of patients on ARV “The World Health Organisation’s countries. Thanks to its experience patients in developing countries. At therapy. This meant identifying all the “3 x 5” initiative launched in December MSF, alongside other organisations, the time, patent-protected triple bottlenecks that were preventing us 2003 – 3 million patients under helped initiate a response to the therapies cost over 10,000 dollars per from making the move to treating treatment by 2005 – certainly gave it a pandemic and compelled others to person per year. And there were many larger cohorts. It led to a simplifica- boost by mobilising the various become actively involved in the fights sceptics – major sponsors in particu- tion of treatment: initiating therapy players” says Annick Hamel from the against Aids. MSF is now innovating lar – who believed that it was impossi- without a CD4 count1, longer periods Operations Department. Even if the an approach to try and treat as many ble, and even pointless. Then the between patient visits, new allocation WHO “3 x 5” was widely disparaged, patients as possible. Our teams are context changed. The Global Fund to of tasks, with a start on training and not only by MSF (see the Win Van already helping 60,000 patients to Fight AIDS, Tuberculosis and Malaria nurses to take responsibility for some Damme interview on p. X), there were survive. was set up in June 2001. With generic patients. more and more initiatives being set up versions coming onto the market, in in the field, and national programmes Ok, but what next? ‘No hailing of 2001 triple therapy was available for In parallel, the “global response” to are gradually starting up. victory” is the message in this less than 350 dollars per patient per the pandemic was making slow dossier. Above all we must not fall year. progress: the Global Fund was having “Decentralisation of care is now into the trap for which we criticised under way in a great many countries, the WHO concerning tuberculosis: in the sense of increasing the number soothing self-satisfaction in order to EPIDEMIOLOGICAL RESEARCH of places where treatment is conceal our failures and difficulties. available, to get closer to the patients Our programmes have their failures, TRANSLATED BY AARON BULL and offer therapy to everyone who and they are considerable: treatment needs it. It’s the only way to cope with We are conducting a series of cross-sectional surveys to determine the is given priority over prevention, the high demand, especially in high- efficacy of treatment for patients being treated by MSF. MSF has a especially in mother-to-child trans- prevalence countries”, Annick Hamel responsibility to be credible, demonstrating that its treatment strategy is mission, the ever neglected element effective. explains. The question is therefore: of our Aids programmes. The how should it be done? In MSF treatment of TB/HIV co-infected Our work involves taking a blood sample of patients who have been programmes, implementing decen- patients is the next challenge for receiving antiretroviral treatment for 12, 24, 36, or even 48 months. If the tralisation also depends on the MSF. A complex challenge that will viral load is detectable, we study the genotype of the virus in order to political will shown by the countries call us to rack our brains. determine the most frequent viral mutations. At the same time, we try to and the constraints they have to face. measure how consistently patients have been following the treatment and “Some countries, such as Uganda, It is because we have made progress assess the side effects they have experienced. We also try to identify have set up a decentralisation policy clinical signs of treatment failure by comparing viral load values with that our weak points and where we that is mainly aimed at meeting target possible clinical signs that may appear during treatment. need to better ourselves are all the figures. Here it is harder for MSF to more visible. That’s all par for the get involved in the process because it This will allow us to make more accurate assessments of our programs, course. MSF can only be considered a i.e. to measure treatment failure rates, adherence problems and has to be done by improving the ‘pioneer’ if it continues to break new treatment toxicity. For patients experiencing treatment failure, analysis of existing system. In Malawi, where ground and improve treatment for the genotype allows us to determine the most suitable second-line there is a willingness at national level, patients. MSF must not be a hero combination. The first studies on adults show immuno-virological results the government is encouraging MSF clinging to past success, but a that are comparable to those in economically developed countries, taking to implement the decentralisation so clinician in the field continually into account the patients’ health condition when MSF began administering they can learn from our experience.” inventing new approaches. their treatment. But in practical terms, the dynamic is Dr Mar Pujades, epidemiologist, Epicentre. the same as for “scaling up”. “It’s only Interview by Olivier Falhun the scale that changes. And one of the P2 messages MSF N°143 November 2006 go along > Nigeria © Ton Koene - July 2006 main issues is the lack of medical reliable supply of drugs, and so on. able to transfer our activities to experience of the first few years. Even personnel. But it’s possible to care for While quality of care is of vital impor- national programmes that are if some teams still feel that treating more patients by asking for help from tance, it is not incompatible with capable of offering good-quality care Aids is complicated, treating a few other patients or people in the quantitative objectives. for stabilised patients, we hope MSF patients as part of their programme is community, to look after the patients will be further ahead: for instance in no longer anything out of the ordinary. close to their home.” Hence the And what about tomorrow? What is treating children, or complicated What is extraordinary is having to experiments in Malawi, for instance, the future for MSF programmes once medical cases in outlying health ‘make it up as we go along’. There is or in Kenya (see also p. 4). all the requirements for treatment at centres. no care model for large cohorts of patients. There has never been a Nevertheless, not everyone wants to There remains the question of chronic disease quite like this, so treat all patients and provide every- treating patients outside the vertical there is no referring back to earlier thing needed to ensure they survive. There has never been a chronic HIV/AIDS programmes. Although MSF practice. We have to invent it, country “We must keep repeating that disease quite like this, so there says it wants to treat HIV/AIDS by country, to suit their specific requi- everyone must be treated. And at the is no referring back to earlier patients within other programmes rements and constraints, so we can same time, it’s important not to forget practice. We have to invent it, where possible, this is still not treat all the patients who come country by country... that treating an AIDS patient is not happening everywhere. At the knocking on our door”. ■ just a matter of making drugs moment it is done in Liberia, Sudan, available”. It also involves making a the Democratic Republic of Congo, Caroline Livio diagnosis, being able to treat opportu- Thailand, Georgia and Ivory Coast. But nistic infections, detecting and population level are covered? “It will as Annick Hamel points out, “treating dealing with treatment failure, never be MSF’s job to treat all a AIDS patients is not that complicated.