In-depth: The Treatment Era: ART in Africa
Celebrating the opening of an AIDS treatment centre in Katima Mulilo, Namibia
JOHANNESBURG, 6 December 2004 (IRIN) - As a result of falling antiretroviral (ARV) prices, new sources of international funding and growing political commitment, providing treatment for Africa's HIV-positive citizens is, for the first time, an achievable goal.
In sub-Saharan Africa 3.8 million people need treatment now, but as of June 2004, only 150,000 were on ARVs - less than four percent of that total. The remaining 96 percent - those parents, workers, lovers and children denied access to the life-prolonging drugs will, unless there is urgent intervention, inevitably join the other 30 million people worldwide that the pandemic has claimed.
PICKING UP THE GAUNTLET
The enormity of the challenge is daunting for a continent that, over the past two decades, has witnessed the attrition of public services and the deepening of poverty. Even Africa's targets under the World Health Organisation's '3 by 5' initiative - three million people in the developing world on antiretroviral therapy (ART) by the end of 2005 - seem incredibly ambitious.
But, although little more than pilot programmes in many countries, the rollout of ART is underway, and lessons are being learnt on the job. "I genuinely believe [3 by 5] is still within reach, and that the momentum is picking up at country level. I don't want to pretend it's going to be easy, though - it's going to be very tough," Stephen Lewis, the UN Special Envoy on HIV/AIDS in Africa, told PlusNews.
What it takes to deliver ART is already well understood, much of it as a result of the pioneering work of Medecins Sans Frontieres (MSF) in South Africa and Malawi. It involves standardised treatment protocols and simplified clinical monitoring; the delegation of aspects of care and follow-up to more junior healthcare workers and the community; the involvement of community members and people living with AIDS in programme design; and ensuring a reliable supply of affordable medicines and diagnostics.
The delivery platform for national programmes is the overburdened and under-resourced public health system, whose decline has been accelerated by the toll of HIV/AIDS. In Malawi, more than half of all government health posts are vacant and, according to a report by the Regional Network for Equity Health in Southern Africa (EQUINET), 90 percent of public health facilities do not have the capacity to deliver even a minimum healthcare package.
Under such conditions, "without urgent measures to recruit and retain healthcare workers, coupled with a system-strengthening perspective, the public health response to HIV/AIDS will be delivered at the expense of public health in general," the EQUINET report noted.
WHO acknowledges that "major new investment in countries' health systems" will be needed - an additional 100,000 health and community workers for a start. It estimates that the cost of achieving 3 by 5 will be US $5.5 billion, but points to the ongoing mobilisation of international finance, and the lasting benefits that well-managed increased spending on ART will have on public healthcare in general.
Given Prime Minister Tony Blair's commitment to driving the AIDS agenda forward, both Lewis and South African treatment campaigner Zackie Achmat highlighted in interviews with PlusNews the significance of Britain's chairmanship of the G8 and European Union in 2005.
However, the issue of resources remains politically charged, with activists demanding that the Global Fund to Fight AIDS, Tuberculosis and Malaria be the primary financing mechanism, to avoid duplication with bilateral initiatives such as the United States President's Emergency Fund for AIDS Relief. In a new report Action Aid has also warned that the International Monetary Fund must relax its restrictions on public spending by African governments if they are to be able to effectively respond to HIV/AIDS.
BUILD IT AND THEY WILL COME?
But where ART is available, stigma, seemingly inexplicably, still influences people's response to treatment.
"Once HIV is perceived as a chronic but treatable condition, one of the factors that amplify stigma - fear of contagion and inevitable death - is lessened. However, stigma is much more than fear of contagion; it is also a tool used by cultures to exclude those felt to have broken extant rules. The dominant stereotype of people living with HIV is a stigmatising one that casts them as immoral," noted an article in November 2004 in the British Medical Journal (BMJ).
The Infectious Disease Care Clinic at Botswana's Princess Marina hospital in the capital, Gaborone, is one of the biggest treatment sites in the world. Many patients travel long distances to get there because of the anonymity the facility provides. Many also arrive sick beyond recovery because they have waited too long to seek treatment, even though Botswana has a well-publicised, amply funded, model ART programme.
It is not just rural people that succumb to stigma. Vodacom, one of South Africa's largest mobile phone companies, has a free treatment programme, but few workers are reportedly accessing it. "Professional relationships still convey a danger of rejection, especially in contexts of conflict or competition", suggested the BMJ article.
ART should be part of a continuum of care: a comprehensive approach that includes voluntary counselling and testing, prevention of mother-to-child transmission, and other prevention and social support services. A regular supply of drugs, treatment preparedness and literacy are important factors in achieving high and sustained adherence rates.
"Rolling out ARVs is okay, but it has to be done right, otherwise it's dangerous - [drug] resistance will make the problem worse," Zambian HIV-positive activist Winston Zulu told PlusNews. "Here, we rolled out without talking about treatment literacy [or] even about the side effects [of the drugs]. Some people have had terrible side effects and stopped taking their drugs."
NOT EVERYBODY WINS
A mix of payment systems - free, subsidised or self-paying - are employed by governments, and criteria for access to ART differ widely. What is increasingly clear, however, is the inequity in access, even when the drugs are free.
"Given their limited access to income and other productive resources, women are less likely to be able to participate in self-pay schemes, even with subsidised prices," a report by the US-based Centre for Health and Gender Equity noted.
"Many families cannot afford to have more than one person on ARVs because of the financial implications, so if there is one person that should go on the drugs, it is usually the man, because as the perceived head of household, he is less dispensable," Karana Mutibila of Zambia's Network of People Living with AIDS told PlusNews.
Because of the additional cost of paediatric ARVs, and the difficulty of calculating the correct dose when using adult ARVs, HIV-positive children are another group that are often sidelined by existing ART.
ARVs represent only around 50 percent of the costs of treatment. In Zambia, CD4 count, viral load, liver function, syphilis and TB are just some of the tests required before ART can start - and they are not free. "People can go to and fro for three weeks [taking tests] before treatment starts, and many of them give up," said Zulu.
A study in Senegal found that when the cost of drugs for opportunistic infections, laboratory exams, consultations and hospitalisation fees are calculated, patients on ART pay an additional US $130 a year - a significant amount for the majority of people who live on less than a dollar a day, and a reason cited for treatment interruptions.
The "Freeby5" campaign argues that any form of payment disadvantages the poor, while exemption systems are not cost-effective. The signatories to the declaration note that a "prerequisite for ensuring that treatment programmes are scaled up, equitable and efficient, and provide quality care, is to implement universally free access to a minimum medical package, including ARVs, through the public healthcare system".
The unfortunate reality is that not everybody who needs treatment will be able to access it - but if you are rich and live in the cities, you stand a better chance. "What we can look forward to is some treatment, for some people, in some settings," said professor Alan Whiteside at the Health Economics and HIV/AIDS Research Division of the University of KwaZulu-Natal, South Africa.
He calls for an informed debate at national and community level about who should get access to treatment, rather than leaving it to the doctors or the ad hoc rationing caused by limited services. Should there be economic criteria, where only graduates need apply? Should it be based on equity, where the most vulnerable are served? Or on moral grounds - the victims of sexual abuse? Most would agree that health workers should top any list.
"People in the north consider that they have a compact with their governments, which entitles them to a certain level of treatment when they are sick. I don't think that's true in the developing world: if you don't think you are entitled to it, or expect to have it, you die uncomplainingly. This epidemic provides room for building civil society [as a political movement around treatment]," Whiteside told PlusNews.
- ART Treatment access and effective responses to HIV and AIDS - Providing new momentum for accessible, effective and sustainable health systems - Equinet: The Network on Equity in Health in Southern Africa - www.equinetafrica.org
- Treating 3million by 2005 - WHO | World Health Organization - www.who.int
- How the Fight against HIV/AIDS is Being Undermined by the World Bank and International Monetary Fund - Action aid U S A - www.actionaidusa.org
- Gender, AIDS, and ARV Therapies: Ensuring that Women Gain Equitable Access to Drugs within U.S. Funded Treatment Initiatives - Center for Health and Gender Equity - www.genderhealth.org]