“We have the tools they’re just not being implemented at the right time” (Dr Kumarasamy). Currently in India the prevalence of HIV is quite low, however due to such a large population the numbers of people living with HIV is high. Sadly only 1.2 million people are receiving HIV treatment which equates to ~50% of infected persons actually receiving antiviral therapy.
“So how do we plug the gaps?” (Dr Kumarasamy)
Cost is a significant barrier to treatment for many people with HIV. Access to more affordable antiretroviral medications is critical and whilst some countries like India have access to generic licences of medications, many countries in the Asia Pacific region do not. Dr Kumarasamy highlights the need and calls for more countries to seek out generic licence agreements so that the cost of HIV medications can be more affordable for those in low and middle income countries.
The day continued with interesting regional insight and perspectives from areas across the Asia Pacific region such as Singapore, China, Malaysia, Thailand and Vietnam. As the day progressed and I learned more and more of the challenges these countries are facing with diagnosing, treating and long term management of people living with HIV and hepatitis C, as well as issues such as cultural stigma and the psychosocial well being of these populations; I could not help but reflect on current practice and the healthcare systems and access we have in place in Australia and not be thankful. However, this disparity of health care and well being for people living with HIV and hep C greatly saddened me. HIV/HCV are global issues and more needs to be done for equitable healthcare access across the Asia Pacific region, however at the same time acknowledge the great work so many organisations represented and in attendance here at APACC today have achieved and continue to drive and advocate for change and to “plug the gaps”.
Today I heard many interesting trials and studies for various HIV ART regimens across the Asia Pacific region and what became quickly apparent was that the high cost of these medications is a significant barrier and often a cause for drop out in studies conducted, with patients having to pay for testing and medications within many study populations. Thu Nguyen whilst discussing the outcome of HCV treatment by direct acting antiretroviral DAA among HCV/HIV co-infections in Vietnam mentioned that close to 1 million people in Vietnam have HCV but the diagnosis and treatment rates are very low due to the high cost of the drugs not covered by any health programs or any available intervention programs. Reflecting on my own area of practice within pharmacy I have seen firsthand the significant impact on the health and well being of people with HCV once access to medications were PBS listed and were now able to be affordably accessed. Going back to Dr Kumarasamy’s comments above earlier regarding generic licensing, again as a pharmacist I have seen the positive impact generic medications has made to medication access affordability. I think to move forward in achieving an end to HIV in the Asia Pacific region the use of generic medication licensing is a critical tool to break down barriers.
Gaps and barriers are not just limited to diagnosis and treatment of HIV but are also a result of lack of adequate optimization and management of associated long term complications. Dr Ruxrungtham from Chualongkorn University in Thailand highlighted that when ART is commenced early (say in a person in their 20’s) the life expectancy of a person living with HIV is comparable to the general population (~80yrs). This means people living with HIV are living longer and as a consequence we are seeing an aging HIV population and emerging associated conditions and co-morbidities such as cardiovascular disease, hypertension, dyslipidaemia and T2DM that are significantly under-recognised, poorly managed and patients fall through the gaps.
Reena Rajasuriar from the University of Malaysia discussed the Malaysian HIV and aging study and found that geriatric conditions are higher in HIV vs. non-HIV populations especially in the areas of cognitive impairment, depression, polypathology and functional disability. Reena highlighted that cardiovascular disease was the greatest contributor with 92% of the HIV study population having cardiovascular co-morbidities present. In terms of falling through the gaps, an audit carried out found that 61% of HIV patients with HTN, 57% with hyperlipidaemia and 27% with T2DM were missed. Cardiometabolic risk factors have a significant impact on the burden of functional aging in the HIV person. “There is room for improvement in addressing long term complications, if we address cardiovascular complications we can alter the issues associated with functional aging” (Reena Rajasuriar).
The question was asked, how are there gaps for these HIV associated co-morbidities? The answer is multifactorial but a commonality appeared to be patients having multiple doctors resulting in a lack of continuity resulting in incomplete diagnosis and screening. Reena highlighted the need for and advantage of multidisciplinary collaborative healthcare for the optimized management of multi-morbidity in HIV. This was particularly relevant to me practicing as a pharmacist; during the course of medication reviews I often come across underlying co-morbidities that are under diagnosed or suboptimally managed. I’m not familiar with the roles of pharmacists within other Asia Pacific countries outside Australia, but perhaps if not already in practice this could be an area of exploration. That is the utilization of the pharmacist by way of conducting services to their HIV clients such as cardiovascular and diabetic screening, as well as home medicine reviews in an effort to optimise clinical management and avoid long term complications in the HIV patient, essentially helping to “plug the gap”.
