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Africa: Year of Action for AIDS Treatment?
AfricaFocus Bulletin
Jan 9, 2005 (050109)
(Reposted from sources cited below)
Editor's Note
"The Indian Ocean tsunami killed 150,000, and triggered a
remarkable global relief effort that has raised $4 billion for the
stricken region. But AIDS, tuberculosis, and malaria alone kill 40
times that number every year, taking no fewer than 6 million lives.
And still, the United Nations must scramble for the $3 billion a
year it needs to combat these diseases." - Toronto Star, January 8,
2005
The torrent of pledges in response to the uniquely visible natural
disaster in the Indian Ocean is a testimony to human solidarity as
well as to the power of today's global media. Contributions include
not only the well-publicized responses from rich countries, but
also less-noticed contributions from countries and regions
themselves burdened with pressing humanitarian needs. [For a
summary of the response from Africa to the Tsunami disaster,
including $100,000 contributions from Mozambique and from the
African Union, see the January 5 article from the Afrol independent
news agency (http://www.afrol.com/articles/15136).]
While the tsunami toll continues to mount, the focus is now less
on pledges than on ensuring that pledged resources are turned into
action. And commentators are also beginning to raise other
fundamental questions. Most significantly, can the response to the
tsunami be carried over to even more devastating crises that are
less photogenic, such as AIDS, global health, conflict, and
poverty? Or will the effect be to reduce resources for implementing
programs that have not been scaled up for lack of political will
and resources?
This AfricaFocus Bulletin contains two articles from a year-end
special by the UN's Plusnews highlighting the current status of
antiretroviral treatment in Africa, an overview and a report from
Mozambique. While the scale of the AIDS pandemic differs
significantly from one African country to another (see
http://www.africafocus.org/docs04/hiv0412a.php), for the worst
affected countries the impact of AIDS alone is orders of magnitude
greater than the toll inflicted by the tsunami on all the countries
involved.
Despite significant expansion of programs in the last two years,
only four percent of the estimated 3.8 million people in need of
such treatment in Africa now have access..Global spending on
HIV/AIDS in low and middle-income countries was estimated at $6.1
billion in 2004, with the need projected at $12 billion for 2005.
The year began with Nelson Mandela's courageous statement
acknowledging that the death of his son was due to AIDS, and
calling on others to speak out as an indispensable step to
countering the disease. The articles below indicate that while the
obstacles of political will and resources are still formidable, the
basic outlines of what needs to be done are in place.
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
Africa: the Aids Treatment Era - Introduction
UN Integrated Regional Information Networks
http://www.irinnews.org
December 31, 2004
Johannesburg
[Excerpts. For full text and additional articles, see the PlusNews
Special at
http://www.plusnews.org/webspecials/ARV/default.asp]
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 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 antiretroviral treatment (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 IRIN.
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. [For this and other Equinet reports, see
http://www.equinetafrica.org]
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 IRIN the significance
of Britain's chairmanship of the G8 and European Union in 2005. ...
Build it and They Will Come?
But where ART is available, stigma, seemingly inexplicably, still
influences people's response to treatment. ...
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. ...
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 IRIN.
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 (http://www.nu.ac.za/heard/free/freeby5.asp)
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. ...
"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 IRIN.
Overview - Focus on Mozambique
Mozambique is a catalogue of the problems that poor countries face
when they expand antiretroviral therapy (ART).
National HIV prevalence in 2004 is projected to be 14.9 percent
among people aged 15 to 49, based on sentinel surveillance by the
ministry of health and the National Institute for Statistics. The
average hides sharp disparities between provinces, ranging from
26.5 percent in Sofala to 8 percent in Nampula. Provinces bordering
South Africa, Zimbabwe and Malawi are the worst affected.
Among the estimated 1.4 million people infected, 218,000 need
treatment in 2004, according a National Institute of Statistics
study.
As of November 2004, 5,900 people were on ART: 4,200 through NGOs,
1,200 at Maputo Central Hospital, a few hundred at provincial
sites, and about 50 through private health care.
The goal was to have just under 8,000 people on ART by the end of
2004, with an annual increase to 20,800, 58,000, and 96,000 -
reaching 132,000 in 2008.
Healthcare Providers
The first problem is lack of human resources. There are 800
doctors, 300 of them expatriates, in a population of 18.9 million.
This means one doctor for every 24,000 people, against one per
5,000 to 10,000 recommended by the World Health Organisation. The
11,000 nurses represent one per 1,700 people, while WHO recommends
one every 300.
Healthcare is also unevenly spread: 80 percent of doctors are in
Maputo, the capital; among all health staff, those in the provinces
have the lowest qualifications.
Due to AIDS-related deaths, Mozambique needs to train 25 percent
more doctors and nurses every year just to maintain the existing
low levels of staffing, says a study by the ministry of health.
The University Eduardo Mondlane, the new National Health Institute
in Maputo, and the new Nursing School in Beira are increasing
student uptake, but to retain them in the country after graduation
will require better salaries and working conditions.
Meanwhile, with donor money to offer monthly salaries of US $3,000,
the government is recruiting 120 doctors in Cuba and India.
Infrastructure
Another problem is poor health infrastructure. In the provinces,
sub-standard facilities and lack of basic equipment is common. Many
of the 27 rural general hospitals operate below minimum acceptable
standards, says the Health Sector Strategic Plan 2002-2005.
To enable ART, the Italian Catholic NGO, Communita de Santo Egidio,
rehabilitated three molecular laboratories with state-of-the art
equipment. The biggest, at Maputo's Central Hospital, cost US
$450,000; those in Maputo and Beira are operational, and Nampula
will open soon to serve the northern region.
In the meantime, blood samples are sent weekly from the north to
Maputo by courier airplane - run-down inter-provincial roads make
some airfreight unavoidable.
The lab in Maputo offers training for health personnel from
Mozambique and other African countries where Santo Egidio plans to
start ART.
At Maputo Central Hospital, Brazilian cooperation funds ARV
training for doctors and nurses, and to date 200 doctors have been
trained, so that every province now has ARV-competent doctors.
Dr Rui Bastos is the Mozambican training coordinator. "We are
overworked," he says. "We lack diagnosis capacity, drugs for
opportunistic infections, nurses, psychologists and resources in
general." ...
Treatment Providers
Two NGOs, Medecins Sans Frontieres (MSF) and Santo Egidio, run
model community-based care and treatment projects: MSF treats 1,700
patients in Maputo and Lichinga; Santo Egidio runs 13 sites in
Maputo and Beira, treating 2,500 patients.
By 2007 Santo Egidio plans to treat 8,400 persons at 20 sites in
five provinces.
In Maputo, MSF is working at full capacity. Its clinic there has
1,500 patients on ART and a waiting list of 1,000. "It is
frustrating, but our human and financial resources are limited,"
says MSF general coordinator Patrick Wieland.
MSF employs 20 medical staff in Maputo, including two Mozambican
and three foreign doctors, and 10 non-medical staff. The total
annual cost of the programme is $2.5 million, but, being
donor-dependent, MSF can only guarantee five years of treatment,
and continuation hinges on additional funding. Patients must
understand this, sign consent forms, and hope.
"It is not our role to treat everyone," says Wieland. "We showed
ART is feasible; we can train others, but we cannot substitute for
the government."
Santo Egidio operates on a different model, at a lower annual cost
of $2.2 million. The Catholic charity relies on volunteers from
Italy and other countries, who pay their travel to Mozambique
during holidays and work one month for free at its sites.
The annual treatment cost per patient at Santo Egidio is $700,
broken down to $300 for generic antiretrovirals (ARVs) and $400 for
tests and other support.
The success of such ART programmes in Mozambique and elsewhere in
Africa lies in strong community involvement regarding patient
identification, selection, care, support and monitoring. It is
labour and capital intensive.
Besides drugs and tests, patients need good food, clean water and
a healthy environment; mothers need formula for babies. Santo
Egidio distributes food, insecticide-treated mosquito nets, water
filters and home-based care kits, while MSF has partners who
provide this support.
Can these schemes be replicated by the public health sector?
"As it is, no," says Wieland. "Local solutions are needed - there
is no other choice."
Gabriella Bortolot, coordinator at Santo Egidio, says: "We can't
export a western model to Africa, but the challenge is to develop
an African model of quality care."
Local solutions include using non-medical personnel at all levels.
Lay community workers, trained and supported by referral systems,
can run pharmacies, do routine follow-up, counselling, and home or
palliative care; nurses and clinical officers can offer
prescription and consultation, while community health workers can
monitor patients for toxicity and clinical failure, freeing scarce
doctors to attend mainly to complications.
Eliminating the requirement for viral load and CD4 counts before
starting treatment bypasses expensive tests.
Expansion
Mozambique began planning nationwide ART in 2002 with a degree of
reluctance: health authorities knew first-hand the problems
involved. "AIDS should not detract from other health services, it
should reinforce them," says Dr Mouzinho Saidi of the National
Programme to Fight HIV/AIDS.
The examples of successful ART schemes run by NGOs helped dissolve
the initial reluctance, but today the government is under pressure
from activists and donors alike to expand treatment access.
"We are resisting donor pressure to increase the numbers because we
want to grow in a sustainable way," says Saidi. "If we lose
control, drugs will end up [being] sold on the streets and patients
will not be properly monitored." The fear of creating resistant
strains of the virus is palpable, as is the fear of donor funds
shrinking in the future. ...
The ethical imperative and the practical feasibility of ART in
Africa are now widely accepted. The challenge is at what pace and
how.
"Scaling-up was decided by donors in foreign capitals, who don't
know the on-the-ground reality of treating patients," says Wieland.
"Westerners like to do a lot quickly, and have quick impact, but we
need long-term strategies to sustain results, not relying on donors
and their whims."
Coordination
Throughout the interview with PlusNews, Saidi stressed one point:
coordination. "We can't have disorganised growth or parallel
systems for treatment, drug procurement and drug supply," he
explained.
Mozambique, like other developing countries, has a variety of
health care providers, including the state, NGOs, churches and the
private sector. ART began in Mozambique with NGOs; the public
health sector came later. The challenge is to coordinate the whole
spectrum of ART providers. ...
Donor Dependency
In UNDP's Human Development Index, Mozambique ranks at 171 out of
177 countries. In 2003 its GNI per capita was US $210, compared to
an average of $450 in sub-Saharan Africa.
In 2000 foreign aid accounted for 70 percent of all spending on
health, 46 percent of education expenditure and 75 percent of the
funds spent on infrastructure, such as roads and water.
In 1999 foreign aid provided 52 percent of the $100 million health
budget, notes the Health Sector Strategic Plan. With increased
foreign funding for AIDS, the ratio is higher today.
Mozambique is one of the most donor-dependent countries in the
world, and its treatment plan echoes this. The government worries
about the long-term sustainability of treatment, and the recent
wrangle among donors about next year's financial support for the
Global Fund to Fight AIDS, TB and Malaria feeds these concerns.
Then you meet Ana Maria Muhai, 43, a dynamic activist in Machava on
the outskirts of Maputo. Her miner husband returned from South
Africa in 1998 with a retrenchment bonus and promptly left her and
their three young children when she became sick.
In February 2002, Muhai, weighing 29 kg, ravaged by opportunistic
infections, bald, with horrible skin rashes and a bad cough,
arrived at the clinic. In three weeks ARVs brought her back from
the brink of death.
Today, a healthy Muhai helps patients with treatment adherence.
When some ask if she is paid by the Italians to say she is HIV
positive, she pulls out an old photo. "Then they see it is for real
- I know it is not a cure, but I feel cured," she says.
There are 1.4 million people like Ana Maria Muhai in Mozambique,
whose contribution to family, community and nation is unique,
irreplaceable, and threatened by the virus.
AfricaFocus Bulletin is an independent electronic publication
providing reposted commentary and analysis on African issues, with
a particular focus on U.S. and international policies. AfricaFocus
Bulletin is edited by William Minter.
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