In-depth: The Treatment Era: ART in Africa

SOUTH AFRICA: Interview with treatment campaigner, Zackie Achmat

Photo: TAC

NAIROBI, 6 December 2004 (IRIN In-Depth) - South Africa's Treatment Action Campaign (TAC) leader Zackie Achmat has been a powerful global voice in the struggle for HIV-positive people to access free antiretroviral drugs.

QUESTION: After the problems seen in Arusha with the Fund's next round and donors' apparent reluctance to increase their funding, what guarantees of sustainability can mass antiretroviral (ARV) treatment have?

ANSWER: What we would like to see, in the long term, for HIV funding sustainability is countries committing at an international level. We'd like to see conditional debt cancellation based on spending on health, social security - which includes food security - and education. And that, taken together with the lifting of unfair trade subsidies, particularly agricultural ones in the developed world, would allow developing countries greater access to the markets of developed countries. So, raising our own funds through taxation will be critical for sustainability.

The Global Fund is also critical, because we're dealing with an emergency and, in the short term at least, the bulk of HIV funding and treatment needs to go through the Global Fund.

Q: Are we urging poor countries to take on life-or-death commitments that are dependent on erratic outside funding?

A: The sad thing is that poor countries are not leading the demand because, just as none of us argue that human security is not a national or a local issue ... it should also be an international burden. For example, the war on terror is funded on an international level, and no one questions that we should all find the funding to deal with it, but when it comes to healthcare or development, the poorest countries, especially, are left to their own devices.

If you take a country like Malawi or Mozambique - they don't have the funds to finance an ARV treatment programme, and where they don't have the funds, it's an international responsibility. The steps taken by [British Prime Minister] Tony Blair and [Chancellor of the Exchequer] Gordon Brown to increase their overseas development aid to 0.7 percent of ... GDP over five years are very positive. At the moment, in the United States for example, overseas development aid amounts to less than 0.05 percent of GDP.

Q: To what extent has the recent controversy around some generic companies withdrawing from the World Health Organisation's (WHO) prequalification list threatened the survival of ARV programmes?

A: In the long term, I don't think it threatens the survival. The way, unfortunately, that some generic companies did their documentation for bioequivalence was a mistake, and helped undermine the confidence in generics. But I think there's a broader question, at the moment, about making all generic companies take responsibility for their mistakes.

From our point of view, the WHO's pre-qualification process is a good one, particularly for countries that don't have the mechanisms to regulate themselves. We need the WHO to bring brand-name and generic companies together to make commitments to encourage competition, and to encourage as many companies as possible to enter the market and, therefore, keep prices down. What we need in the longer term, if we're going to get 3 to 5 million people on treatment, is to encourage competition for price reduction and sustainability to ensure supply.

Q: Isn't there a danger that the positive living aspect of HIV/AIDS treatment is being lost with all the focus on antiretroviral therapy (ART)?

A: The problem is, there's not enough proper focus on ART and how it could be integrated with other aspects of treatment and prevention. Providing ARV treatment presents opportunities, which are not only important for positive living but for prevention, because our prevention efforts so far have been pretty much a shotgun approach.

But with the scaling-up of treatment, WHO in particular has a role to play in seeing that national programmes encourage HIV-positive people to play a role in prevention. So if you come and collect your ARVs you get your condoms, and in that way we combine our prevention and treatment programmes.

The problem is, if you take South Africa, for example, it's not helpful when you get people saying we first have to solve poverty and nutrition before we can treat people - it should never be either nutrition or ARVs. The epidemic presents an enormous opportunity to talk about the economic future of women and marginalised young men, and we need to see prevention, treatment and development as part of the same continuum, as social justice issues. As activists we've always said you can't, for instance, talk about ARV treatment without talking about health sector reforms. The difficulty is when you have agencies coming from a conservative background, pushing a certain agenda, it makes it hard to push social justice aspects.

Q: What do you think are the key components of a successful government rollout of ART?

A: Political leadership, sustainable funding and, most importantly, community mobilisation for treatment preparedness. Also, a national human resource plan to strengthen the whole health sector, and to integrate sexual and reproductive health, [and] include prevention of HIV. There obviously also has to be a positive living aspect at a primary healthcare level. And it goes without saying that programmes for treatment of opportunistic illnesses, like TB and malaria, must be part of [the] programme. It's an enormous opportunity to strengthen the public healthcare sector and to make health everyone's human right.

Q: Beyond the rhetoric, are people living with AIDS really considered an asset in the response to HIV and AIDS, rather than the source of the problem?

A: Two things I think are a problem - one is that there's not sufficient understanding: the most critical agents of prevention should be people living with HIV; they're an enormous human resource to communities, but also at a governmental level. Unfortunately, governments and agencies, and even the private sector, hope to utilise HIV-positive people as faces and as tokens, rather than as active, critical participants.

On the other hand, we, as people living with HIV, must never assume a holiness and be self-righteous about our status. In TAC, for example, my colleagues who don't have HIV work 10 times as hard as those of us who do. They have an equal right to contribute on an equal basis.

The Treatment Era
ART in Africa

December 2004
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Links & References

The WHO 3 by 5 Initiative
www.who.int
The Global Fund to Fight HIV/AIDS Tuberculosis and Malaria
www.theglobalfund.org
The President's Emergency Plan for AIDS Relief
www.usaid.gov
World Bank AIDS site
www1.worldbank.org
Pan-African Treatment Access Movement
www.patam.org
WHO Prequalification Project
http://mednet3.who.int/
Eldis Resource on ARVs
www.eldis.org

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