By the late 1990s, antiretroviral (ARV) treatment had already transformed AIDS for people in the US and Europe from a death sentence to a chronic life-long disease. The introduction in 1997 of an effective triple therapy gave people living with the HIV virus the expectation that they would now live longer if they took medication every day. However the cost of the drugs - around 10 000 US$ - put treatment beyond reach for the millions of people living with the virus in developing countries. Most experts also maintained that the treatment was too complex to be implemented in developing countries and essentially these patients were written off.

MSF refused to accept this situation and in 2000 started ARV treatment in a project in Thailand and the following year opened projects in six further countries across Asia, Latin America and Africa. At that time, less than 1% of all patients needing treatment had access to ARVs.

Seven years on, the situation has changed. Many more patients are receiving treatment as the cost of ARVs has plunged dramatically through competition between pharmaceutical manufacturers - it now stands at just under 100US$ per patient.  Treatment too has been simplified with the development of  generic three-in-one combination pills (fixed-dose combinations or FDCs).

All this was possible because affordable versions of ARVs were manufactured in countries like Brazil, India and Thailand, where they were not patented. As a result, many people who would have died without treatment are now alive and doing well.

MSF today provides ART to over 100,000 people in more than 30 developing countries. Across the developing world, a total of two million people are now receiving ART, but the five million more patients who are still in urgent need of ART are a sign that progress has been too slow. And multiple barriers exist on the road ahead to making sure all people in need of treatment for life are ensured access to that treatment.

The second wave of the access crisis
Life-long treatment means that people have to take their pills every day, but also that they need newer drugs once they no longer respond to the medications they are taking. This is because of resistance that develops naturally, or because they suffer from intolerable side effects. While access to the first generation of ARVs has increased in the developing world, few options remain when people need to be switched to different drug combinations: newer ARVs are often unaffordable or unavailable.

With countries like Brazil and India now granting pharmaceutical patents, there is a serious risk that sources of affordable newer ARVs will dry up. And with the number of people who will need to have newer medicines set to rapidly increase over the coming years, this could mean that once again the cost of treatment becomes a death sentence for people living with HIV/AIDS in the developing world.

Inadequate tools create further barriers to treatment
Beyond price and availability of ARVs, another major challenge is that medical tools are not adapted to the conditions and needs of developing countries.  For example, we don’t have enough medicines available formulated specifically for children, we don’t have simple enough tests to find out whether very small children (under 18 months) are infected with HIV in many settings where we work, and we don’t have a simple test that can be used in remote settings that will tell us if a patient’s treatment is failing and should be changed.

Shortage of health care workers limits access to treatment
Lack of skilled health care staff is a major obstacle in many regions to scaling up treatment of HIV/AIDS especially in rural areas. Health services are often understaffed and health workers are badly paid and supported. International donors are generally reluctant to provide fund to contribute to recurrent health care costs, in particular salaries.

"Providing HIV care in rural clinics depends on nurses, but they are overwhelmed by the number of patients. Constulation times are too short and sick patients suffer needlessly. When nurses suffer, patients suffer."
Dr. Pheello Lethola, MSF doctor in Lesotho

Read more Help Wanted: MSF report on healthcare shortages

Co-infections with the HIV virus compound medical challenges
MSF today also faces further challenges treating the rising numbers of people with HIV/AIDS in our projects whose weakened immune systems make them prone to getting other ‘opportunistic’ infections, notably tuberculosis (TB). TB remains the leading killer of people with HIV, yet we lack the tools to adequately diagnose the co-infection or treat it.