The Treatment Era: ART in Africa

Friday 15 December 2006
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The Treatment Era: ART in Africa

AFRICA: Interview with Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa

Stephen Lewis UN Special Envoy for HIV/AIDS in Africa. Credit: IRIN

Stephen Lewis is the UN Special Envoy for HIV/AIDS in Africa, and has been a key campaigner for urgent and robust international action to meet the challenge of the pandemic. He spoke to PlusNews about his optimism over the '3 by 5' initiative.

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

ANSWER: My own feeling is that it will be impossible for the western world to turn off the financial tap once the treatment is underway. The treatment will be abridged by the amount of money available, but I think however many people are put into treatment, that treatment will be sustained. I do not foresee a situation where the resources will suddenly be cut off in the middle of the treatment.

I also feel confident that we're going to turn a significant financial corner in 2005; that there's something really important happening, which isn't fully understood yet, and that's that the United Kingdom is taking over the AIDS agenda. The UK has the chairpersonship of the G8 next year, and of the European Union. They've already said they're going to host the Global Fund meeting in September, and they've asked for a major meeting in March to bring together all the major players.

[Chancellor of the Exchequer] Gordon Brown is pursuing relentlessly [industrialised countries], moving them to the 0.7 percent of GDP target for ODA [Overseas Development Aid]. The way in which the United Kingdom is taking on this agenda finally gives leadership to what has been the most difficult problem on the planet: the leadership simply has not been there before.

So, I have a cautious optimism that we're about to see a significant jump in resources. And I'm one of those people who still believe that it is possible to achieve the WHO's [World Health Organisation] target of three million people in treatment by 2005. I genuinely believe it's 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.

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

A: In a sense we are. Let's take Lesotho, for example: they want to have 28,000 people on treatment by 2005, and this is without question one of the poorest countries on the face of the earth; a country that lacks capacity and has one of the highest prevalence rates in the world. Nevertheless, the government is so determined to save its people that I feel nothing will stop them, and if Global Fund money suddenly dried up, they'd be on the hook, but I don't believe their treatment programme would fall apart - because every one of these countries understands they are in a life-or-death struggle. Personally, I don't believe they'll be faced by abandonment but, if that terrible prospect happened, they would somehow sustain treatment.

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

A: I don't think it's threatened it one whit. I think what is important is to recognise that what the WHO was doing was being fiercely protective of quality assurance. I think the significant thing that's happened is not that the drugs were de-listed because they're of lesser quality, but because some of the bioequivalence work done by others was shoddy.

What I think is really important is the fact that two of [generic drug manufacturer] CIPLA's drugs have been reinstated after they were given appropriate bioequivalency studies. In early 2005 I think you'll see additional drugs reinstated and new drugs put on the list. The WHO's 3 by 5 programme and its prequalification process, and the support they've given for generics, are among the most dramatic and visionary interventions of any made by the UN since this began.

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

A: There is inevitably the argument being put that prevention is being sidelined by this obsession with treatment, and that nutrition is being diminished somewhat, and that the various opportunistic infections are being inadequately attended to, and that the simple truth of positive living is being diminished because of the obsession with ARVs - I understand that. But my own feeling is that once we get treatment significantly underway, everything else will be given it's due.

It was inevitable, as you have 25 million people in Africa fighting for survival, that the treatment process would preoccupy us. But it will calm down and, as it does, the focus on positive living and nutrition - all these things - will reassert their place again. I don't really think they're being lost, but I think the debate and the loud discourse about treatment inevitably takes the centre of attention.

[Meanwhile] the health sector must benefit from what's happening, otherwise it makes no sense - it must include the building of capacity: they won't be able to sustain the treatment unless they have greater capacity. In many ways capacity is an even greater hurdle than the flow of resources. Treatment must not displace all the other priorities in the health system. We have to recognise ARVs are the centrepiece of the struggle at the moment, but the treatment of AIDS must be seen as a way to strengthen capacity and infrastructure.

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

A: Number one: there must be a voluntary testing and counselling culture developed in the country - testing must become central to the response and very careful and sophisticated counselling techniques must be developed and honoured and implemented. Number two, I think, is the constant and steady and reliable flow of drugs - those drugs must never be interrupted. Overall, it would be preferable to have the fixed-dose combination generic as the first line of response. It may be that the brand-name products will one day come up with a fixed-dose combination of their own but, at the moment, we need a continuous flow of the fixed-dose combination drugs.

Number three: we need the facilities and the capacity to sustain the treatment, and that means an adequate number of health professionals, which means an emergency training intervention - you don't always need a doctor or even a nurse, but you do need people who are carefully trained in the minimum requirements.

We can't continue to lose health professionals from these high-prevalence countries - western countries have to come up with an agreement whereby we won't be poaching health workers from these countries; they have to be paid an adequate salary and given benefits, so that they'll be induced to stay in their countries.

The fourth component is to make sure that you have a network of community health workers, who can follow the people who have AIDS back into their communities and make sure the regimens are adhered to, and that resistance or side effects are dealt with - the most recent UNAIDS report showed that 90 percent of the care is being done at a community level. I'm probably missing many things, but for me those four points are key.

There's another ingredient people don't talk about enough, and that's food; I'm not merely talking nutrition; I'm talking survival - enough food not to be starving and perpetually hungry; so hungry it robs your immune system of its ability to fight the virus. The problem of food in so many of the southern African countries is desperately acute.

Again, you have a UN agency which is showing an astonishing resolve and response, and that's the WFP [World Food Programme]. What they're doing at a country level - you just have to see it to believe it. They've completely enlarged their focus, so they're not only responding to natural disasters, they're responding to the human predicament of AIDS.

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: I think the rhetoric is largely illusory - I don't trust the rhetoric. When I travel I don't see it being translated into genuine respect for people living with AIDS, and recognition of what they can contribute. A lot of it is extremely pro-forma and offensive, and it's used as a way of fobbing off the issue. I think it varies from country to country but, in most cases I've encountered, the government considers the people living with AIDS, who are leading the fight against prevention, as more of a nuisance than real contributors.

They just simply don't get enough of a hearing, because it's not yet understood that they can contribute because they are the experts - they know everything about the virus. They should be meeting with ministries of health on a daily basis and talking to all the other sectors, including education and agriculture, and they should be demonstrating to governments - whether it's through the workplace or community programmes - how you overcome stigma. They should be integrated completely into public policy at every level and in every sector, and they are not.

I never see due respect for the very knowledgeable and important community of people living with AIDS. I'm constantly reminding communities and governments that it's not just respect that's needed, it's also a recognition that you can't afford to lose this body of knowledge.


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