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HIV and the Developing World

In the developed world, antiretroviral treatments (ART) are the standard therapy for HIV infection. But such treatments are rarely simple, often involving numerous drugs that need to be taken at precise times. It's not unusual for those receiving ART to see the therapy lose efficacy due to insufficiently diligent adherence to the treatment regiment.

One common sense reaction to this risk is to emphasize the importance of ongoing attention to the patient by doctors, therapists and the patient's social circle. In the developing world, however, with fewer resources available to medical professionals, this common sense reaction becomes an assumption that ART efficacy will be lower, simply because the patient will receive less persistent attention from his or her doctor. Louise C. Ivers, David Kendrick and Karen Doucette at the University of Alberta's Division of Infectious Diseases decided to test this assumption, and their results could have significant impact on how HIV is addressed globally.

It turns out that there's no significant difference in the success of ART in the developing world vs. the developed. For patients in both regions, the success rate for adhering to the drug regimen for 12-18 months is the same -- about 60%. This is good news, as it undercuts the argument that support for distribution of antiretroviral therapies in the developing world should be limited because HIV patients in resource-poor regions couldn't stick to the regimen. But Ivers, Kendrick and Doucette found something even more important:

The proportion of subjects with an undetectable HIV viral load provided the measure of treatment efficacy. [...] The provision of medications free of charge to the patient was associated with a 29%31% higher probability of having an undetectable viral load at months 6 and 12 than was the requirement that patients pay part or all of the cost of therapy.

Developing world HIV patients were 30% more likely to adhere to treatment regimens when the drugs were provided for free. This strongly suggests that a major impediment to sticking with the therapy is the sheer cost of the medicine, even when sold at cut rate prices. On one level, this is unsurprising, but the level of difference free antiretroviral drugs can make is startling. Free medicine would allow nearly one third more HIV-infected people in the developing world to live with an undetectable viral load.

Given that, of the 40 million people globally living with HIV/AIDS nearly three-quarters are in sub-Saharan Africa, a 30% increase in the ability to follow the treatment could potentially mean millions more lives saved -- not even counting the millions more who would be saved who couldn't even afford the low-cost ART in the first place. While "free" as in "libre" is definitely important, sometimes "free" as in "gratis" can be pretty damn worldchanging, too.

Comments (4)

Cameron Sinclair:

It doesn't matter if you make the ARVs' free, there is no widely distributed network of healthcare facilities in place to deal with the extent of this pandemic.

In order to achieve this there needs to be a rethinking of care to a more decentralized system, impoved provider care and locally based support network.

I still agree, cost need to come down but so does the doctor/patient ratio.


Cameron is right, a more decentralized care system should be designed and implemented. The questions are what system would work best? (Or should it be designed from scratch?) And how to implement a system like that + lower costs for ART drugs.

[Sidenote: Possibly a country like Brazil's method may be a way for cheaper treatments, in the sense that they have threatened a company to either lower prices or they break drug patents to have affordable drugs available for their population. The question is if Africa wouldn't be hurt by the consequences.]

I'd love to hear some ideas when it comes to a decentralized care system. Anyone got any?



In the name of ideas, how about advertising bundled on the medicine packages as a way to help either lower the price or get medicines sponsored?

It's not the most attractive solution, but it has been proved that advertisments on / in a product can pay for the product. (See www.anarchyonline.com Anarchy Online is an online rpg that recently became free, both of subscription charges and the price of the game itself. The reason was that they started with none instrusive advertising ingame. (The usual poster ads and so on. It works and people don't mind because the game is now free to play.)

So ... it could work and it couldn't, it's after all just an idea. Any input anyone?


The provision of ARV reduces virus to an undetectable level, OK are those individuals still infectious, at the same rate or ata lower rate.

The reduction is temporary or permanent? Will the vrus mutate so as to at a later date re-establish HIV and AIDS.

Do we know these answers.

Are we by giving ARV increasing the effectiveness of the HIV virus in spreading to more hosts.

Has anyone done a systems analysis.


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