Monday 26 January 2009

Natural selection

In the training just completed, as usual we discussed how to select recipients of antiretroviral therapy (ART). Of course, in an ideal world, everyone who needed ART (or at least those who meet the criteria) would get it free of charge. And currently that is the situation in Indonesia, although of course not in every third world country. But according to the Indonesian communicable diseases directorate (CDC), today less than 11,000 people are being treated.

A couple of years back, Dr Sigit, the head of the AIDS Sub-Directorate at the CDC, estimated that by 2010, 100,000 people would need treatment. Given an estimated 273,000 people living with the disease in Indonesia, that number is not unlikely. Of course it is most unlikely that the current testing policy will identify even half of this number, but even that would suggest a possible fivefold increase in those on ART by the end of next year. Such a scale up is by no means impossible; several countries in Africa have increased their numbers on ART more quickly. But what about funding?

We are told that the MoH now pays Kimia Farma Rp 400,000 per person per month for the first line regimen. That amounts to more than US$ 400 per person per year. Thus currently the government is paying moer than US$ 4 million a year for first line drugs - and having difficulty finding the cash. Only a few months back, Kimia Farma stopped shipping the drugs, because they could no longer afford to provide credit to the government - who owed them for almost 9000 patient-months of one drug. A disaster was only avoided by the National AIDS Commission paying some of the bill.

So, if we have difficulty supplying the drugs for 10,000 people, how on earth will be find the cash for 50,000? Unless someone comes up with a solution, there will have to be some rationing, which means selection, which means that someone must decide who lives and who dies. In our training session, which is aimed at opening the minds of some of the activists, we discuss some of the options for selection: priority for pregnant mothers, for example, or for families with young children. We discuss whether the current system of providing ART free to all, regardless of ability to pay, can be sustained, and if not, how we identify those who should contribute. (As an aside, many of the participants spend more than Rp 4 million a year on cigarettes!)

As a theoretical exercise, this session is always interesting. Few participants have thought about this, and for the many who have already suffered through drug shortages, it's anything but theoretical. And does cause some anxiety.

But is this scenario likely? Difficult to tell. The Clinton Foundation claims that it can procure the same first line regimen oat under US150 per person per year. At this price, the current budget could provide ART for more than 25,000 people. And prices continue to dive. In addition, several local administrations are considering some form of funding for ART, and it should be possible to persuade some employers to come to the party. Then there's the insurance companies... If we coordinate all of these sources, we should be able to cope.

On the other hand, an increasing number of people will be needing (still pricey) second-line therapy as their current regimen fails. And every year the number needing ART will increase. The spectre remains...

Babé

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