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Africa: AIDS Activists Speak Out
AfricaFocus Bulletin
May 21, 2010 (100521)
(Reposted from sources cited below)
Editor's Note
"In 2001 in Abuja, African heads of state promised us 15% of budget
spending on health - where is this money? ... Only two countries in
the continent have met the Abuja target, which African finance
ministers recently dismissed as a colossal mistake. the true
colossal mistakes are the wasteful spending habits of many
governments who prioritise wars, luxury for politicians and sports
over social spending, which cost thousands of lives every day".-
James Kamau, Kenyan Treatment Access Movement
Kamau was one of a group of African health and human rights
activists who met in Dar es Salaam on the eve of the World Economic
Forum meeting there early this month. Tanzanian authorities banned
a proposed march, which was then cancelled. But after the activists
presented a statement to Forum representatives on May 6, nine of
them were detained and later expelled from the country. The
following week, eight AIDS activists among a group of 500
protesters demonstrating in New York outside a fundraising speech
by U.S. President Obama were arrested (see http://tinyurl.com/hivdemo1 and http://tinyurl.com/lkspeech). Although
the two events received relatively little media coverage, they
showed the growing outrage among activists at government betrayals
of previous commitments to achieve universal access for AIDS
treatment.
This AfricaFocus Bulletins contains two press releases from the
AIDS activists who gathered in Dar es Salaam, and a statement by
U.S. activists released at the demonstration in New York, along
with an memo on U.S. policy by South African AIDS activist Zackie
Achmat.
Another AfricaFocus Bulletin, available on the web
(http://www.africafocus.org/docs10/hiv1005b.php), but not sent
out by e-mail, contains a press release and substantive excerpts
from the latest report by the International Treatment Preparedness
Coalition (ITPC), documenting early warning signs of declining
international and national commitment to universal access to
treatment for AIDS, in Kenya, Malawi, and Swaziland as well as 3
non-African countries (India, Latvia, and Venezuela). The full ITPC
report is available on http://www.itpcglobal.org
For previous AfricaFocus Bulletins on health issues, visit
http://www.africafocus.org/healthexp.php
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
AIDS activists detained by Tanzanian Authorities at World Economic
Forum on Africa
6 May 2010
Press Statement:
AIDS Rights Alliance for Southern Africa (ARASA)
http://www.arasa.info
Contact Persons:
- Paula Akugizibwe (ARASA) +27 83 627 1317
- Bactrin Killingo (ITPC) +27 73 392 3377
- Linda Mafu (WAC) +27 72 896 2453
- Sydney Hushie (GYCA) +233 244 50 56 57
Thursday 6 May, Windhoek -- On Wednesday 5 May, the opening day of
the World Economic Forum on Africa (WEF) in Dar Es Salaam, a group
of nine AIDS activists from across the continent were detained for
questioning by Tanzanian authorities after they handed over a
memorandum entitled "Health is Wealth", which emphasised the need
for increased investment in health and particularly HIV, TB and
Malaria in Africa, to two prominent speakers at the WEF.
Yvonne Chaka Chaka, a popular South African musician and UN
Goodwill Ambassador for the region, and Christoph Benn, the
Director of External Relations for the Global Fund to fight AIDS,
TB and Malaria, had arranged with the group to receive the
memorandum from them outside the conference centre.
The small group had been delegated by 40 NGO representatives from
more than ten African countries, who were gathered in Dar Es Salaam
to discuss global and regional advocacy strategies to address the
urgent need for resource mobilization for universal access to HIV
prevention, treatment and care (universal access), and for
replenishment of the Global Fund in October 2010.
One such strategy included the submission of a memorandum to
participants of the World Economic Forum, which outlined the
concerns and demands of civil society organizations working on HIV
and TB in response to the rapid backtracking of both donors and
national governments on their commitments to funding universal
access.
The group had chosen the WEF as a focal point for advocacy because
of the inextricable links between health and socio-economic
development. As mentioned in the memorandum, African heads of
state, in the Abuja Declaration of 2001, stated that HIV, TB and
other infectious diseases "constitute not only a major health
crisis, but also ...the greatest global threat to the survival and
life expectancy of African peoples, [and] a devastating economic
burden, through the loss of human capital, [and] reduced
productivity..."
In calling on global leaders to mobilize at least US$20 billion for
the Global Fund replenishment in October 2010, the memorandum also
pointed out that, as warned by the World Bank, "responding to
immediate fiscal pressure by reducing spending on HIV treatment and
prevention will reverse recent gains and require costly offsetting
measures over the longer term".
The memorandum was originally intended to be handed over at a
peaceful march with around 800 supporters, largely from Tanzanian
community groups. However, the march was cancelled the night
before, after the government revoked the permit to demonstrate.
Following the handing-over of the memorandum to Chaka Chaka and
Benn outside the WEF, which lasted no longer than 15 minutes and
caused no disruption to the conference activities, the group had
boarded their bus and were preparing to return to their hotel when
they were detained by police and taken to the police station for
questioning. They were held for five hours, although ultimately no
charges were issued or arrests made.
The group was then escorted under heavy security back to their
hotel, where they were instructed to gather their luggage and
proceed to the airport to wait through the night, under police
supervision, until their flights departed from the country the
following day. Although no formal "Prohibited Immigrant" notices
were issued, members of the group were effectively treated as such
and one member, who had planned to extend his stay by a few days,
was compelled to accompany the group to the airport on standby for
the next available flight.
Michaela Clayton, Director of the AIDS and Rights Alliance for
Southern Africa expressed her concern about these actions on the
part of the Tanzanian authorities, 'which display a complete
disregard for the right to freedom of expression in respect of the
conveyance of a message as critical as this. Unless donors and
national governments make more resources available there will be no
universal access".
Those detained were: Paula Akugizibwe and Lynette Mabote from the
AIDS and Rights Alliance for Southern Africa; Bactrin Killingo,
James Kayo and Netsayi Dzinoreva from the International Treatment
Preparedness Coalition; Linda Mafu and Soraya Matthews from the
World AIDS Campaign; Sydney Hushie from the Global Youth Coalition
on HIV/AIDS; and Michael O'Connor from the Global Fund to fight
AIDS, TB and Malaria. All have now left Tanzania.
Press Release: African activists decry backtracking on health
funding commitments at opening of World Economic Forum on Africa
African Civil Society Activists 4 May 2010
Governments being callous and unwise about health commitments
Contact details:
Paula Akugizibwe (ARASA), +27 83 642 0817
Bactrin Killingo (ITPC), +27 73 392 3377
Florence Umunna-Ignatius (PATA), +234 805 958 8858 / +234 806 001
4885
James Kamau (KETAM), +254 722 88 66 94
Catherine Tomlinson (TAC), +27 21 422 5463
Tapiwa Kujinga (PATAM), +263 912 318 638
Lydia Muhengera (TASO), +256 772 448 102
Dar Es Salaam - Donors and African governments are making callous
and unwise decisions on funding commitments to HIV and global
health, according to a group of African health and human rights
activists gathered in Dar Es Salaam, Tanzania, to carry out
strategic planning and advocacy in the lead-up to the World
Economic Forum on Africa from 5-7 May.
Vuyiseka Dubula of South Africa-based Treatment Action Campaign
highlighted the far-reaching benefits of initiatives such as the
Global Fund to fight AIDS, TB & Malaria, and the United States'
government's President's Emergency Plan for AIDS Relief (PEPFAR),
both of whose future is uncertain due to funding cutbacks. "Thanks
to the combined effort of the Global Fund and PEPFAR, more than
5,000 lives a day have been saved for the past ten years", she
said, "but we know that the success does not end there".
There is a large body of scientific evidence demonstrating that HIV
funding has strengthened health systems, improved maternal and
child health and reduced the incidence of other major diseases like
TB. By 2015, HIV in newborns could be ended if adequate funding is
provided. Dubula warned that "if we do not invest adequately to
sustain and build on this hard-won success, then we are effectively
dismissing the right to health and throwing out the health-related
Millennium Development Goals".
There is increasing political hostility towards funding the
universal access to HIV prevention, treatment and care that has
been repeatedly promised by leaders around the world. Paula
Akugizibwe from the AIDS and Rights Alliance for Southern Africa
said that clear public health and socio-economic gains do not
appear to have convinced funders of the need to sustain scale-up of
HIV programs, stating that "we have heard every line in the book
from funders except the truth - namely, that because HIV treatment
is expensive, they are no longer interested in universal access.
This is callous and short-sighted, and sets an unacceptable
precedent for the global response to costly health needs in the
future such as drug-resistant tuberculosis."
Bactrin Killingo of the International Treatment Preparedness
Coalition (ITPC) described the backtracking on universal access as
"heartbreaking". He outlined the findings of a 6-country
community-driven research report issued by ITPC last week, which
warned that HIV could once again become a "death sentence" for
people in the developing world if funding cutbacks persist.
He further warned that "all that these cutbacks achieve is to defer
and increase costs," pointing out that research by various
institutions including the World Bank has shown that the long-term
costs associated with neglect of HIV and other health needs are far
greater than the immediate costs of associated with mounting an
adequate response to these needs.
Florence Umunna-Ignatius from Nigerian group Positive Action from
Treatment Access elaborated on some of the consequences of funding
cutbacks that have already been witnessed in Nigeria, where
shortages of test kits are restricting access of new clients to
testing and treatment. Similar reports have emanated from Uganda,
where people in need of HIV treatment to stay alive are being
turned away from clinics due to flat-lined PEPFAR funding, and the
National AIDS Commission recently announced that treatment for the
350,000 people in need is unaffordable. "Let us not forget that
each of the figures in these big numbers represents a real person
for whom decisions on funding are literally a life or death
matter," she urged.
But to governments, these decisions are often more a matter of
political sport - according to James Kamau of the Kenyan Treatment
Access Movement. "In 2001 in Abuja, African heads of state promised
us 15% of budget spending on health - where is this money?" he
asked. Only two countries in the continent have met the Abuja
target, which African finance ministers recently dismissed as a
colossal mistake.
According to Kamau, "the true colossal mistakes are the wasteful
spending habits of many governments who prioritise wars, luxury for
politicians and sports over social spending, which cost thousands
of lives every day". He brandished spoof dollar bills highlighting
examples such as the cost of President Yoweri Museveni of Uganda's
private jet, which could have paid for HIV drugs for more than
200,000 people.
Tapiwa Kujinga of the Pan-African Treatment Access Movement
outlined the activists' demands to leaders at the World Economic
Forum on Africa, which include setting a clear time-bound roadmap
to achieving the Abuja target of 15% of health and ensuring more
transparent and accountable use of health funding. They are also
calling on global leaders, particularly the G8 and G20, to fully
replenish the Global Fund in October 2010; and on President Obama
to ensure that PEPFAR supports addition of new patients onto
treatment in future. Tomorrow (Wednesday 5 May) they will stage a
demonstration at the World Economic Forum where a memo detailing
these demands will be handed over to a representative of the
Tanzania Minister of Health and the Global Fund, to champion these
messages at the WEF.
Memo to the US Government -- We will reverse your policy through
activism locally and globally
Zackie Achmat
May 13, 2010
On 22 August 2006, Senator Obama met with the Treatment Action
Campaign in South Africa. He visited Khayelitsha -- a place that I
regard as the home of people living with HIV across the world.
There Norute Nobula explained to him how medicines saved her life
and Sizwe Nquqe explained how TAC organises young people with
prevention and treatment messages. Phumeza Runeyi explained our
campaign against gender-based violence to the President. He visited
the Site B Clinic -- the oldest community-based ARV programme on
the African continent started by Medicins Sans Frontieres in
partnership with government and saw how thousands of lives were
saved in that community alone. Across our country, the SA
government has put the majority of people on treatment but former
President George Bush's PEPFAR helped save the lives of the 1
million people on treatment in South Africa. President Obama knows
all these things first hand and he took an HIV test in Kenya where
his father's family lives and another place where PEPFAR works.
He gave us his word that he will work for the US play an
enlightened role in global affairs especially and that he will help
to ensure increased support for HIV, health and development as
opposed to war. Central to his Senate agenda would be work to
strengthen the Global Fund Against TB, AIDS and Malaria. He also
promised to campaign for the first National Strategic Plan for HIV
in the US. When President Obama was elected we all celebrated and
his election will forever be an affirmation of the dignity of every
human being but particularly Black people across the world.
The memo below this introduction explains why we protesting
President Barack Obama in New York today. When Mbeki was removed
from power and the ghosts of two million dead receded, most
activists could catch a breath, now a new sense of foreboding in
relation to HIV has returned. After a decade long battle and a two
year respite, a new unnecessary battle lies ahead for people living
with HIV, one where people who love and respect one another
(irrespective of differences) will find ourselves on opposite sides
when there are so many other pressing battles we will have to
fight. President Obama's struggle for healthcare, financial
regulation, economic growth and jobs, environmental justice,
immigration reform and equality for LGBTI people are fundamental to
secure a more just world for all of us. These are some of the
issues that we all have to work on.
Tragically, the President has inherited a local and global economic
catastrophe, two wars, phenomenal public debt and much more. His
election has also galvanised the deep race, class and religious
hatred of the Republican Right. We understand this cannot be fixed
in a day -- or a decade. However, the misguided manner that
President Obama's advisors are seeking short-cuts to solve these
incredibly difficult questions of HIV, health and development will
rebound not on them but on his Presidency because he will take the
decisions to decide who will live and who will die. It is my view
that the President is ill-advised with "quick-fix solutions" and
"good public-health" sound bytes. These solutions are disguised as
a broader "global strategy for development" but they are another
way of making poor, working and middle class people pay for the
crisis. Investment in health, HIV and broader development is not
only the right thing to do -- new investments in health-care and in
HIV result in growth and improved quality of life for the most
vulnerable.
Today, I will join my US comrades in a demonstration to reverse the
course of the Obama administration. We will not rest until we
ensure that the US and all OECD countries play their full part in
saving lives because we really can end the epidemic. We will work
with the President and his advisors to reduce costs, clean-up
corruption and further reduce medicine prices as we will support
him on all other progressive initiatives. However, in every part of
this world but particularly in Africa, my home, we will resist an
abdication by the US and the other OECD countries of their
international human right law duties to ensure that people living
with HIV have the right to life and access to health-care as
defined in the Universal Declaration of Human Rights.
Zackie Achmat
Memo from US Activists
Date: May 13, 2010
Re: Administration Global AIDS Funding Levels and Policies Risk
Undermining Success
The negative impact of Obama Administration funding recommendations
and policy decisions on AIDS treatment roll-out in Africa is
garnering increasing attention. A growing number of media reports
and comments by experts, researchers, activists, and Members of
Congress share the same troubling message: this worrying trend
undermines broader Administration global health and development
efforts.
Approximately 4 million of the estimated 14 million people in
immediate need of AIDS drugs in developing countries currently have
access to them--with the U.S. directly supporting over 2.4 million
people. Where treatment has reached high levels of coverage,
substantial benefits have been shown including: decreased overall
mortality, increased life expectancy, decreased HIV-negative child
mortality, and increasingly there is evidence of decreased
infection rates.
President Obama, Vice President Biden, and Secretary of State
Clinton all made repeated public commitments as presidential
candidates and as Senators to continue this positive trend.
Specifically, they promised to invest $50 billion over five years
for AIDS and to reach one-third of those in need with AIDS
treatment through direct U.S. support. However, recent public
assessments of U.S. government actions on AIDS in Africa describe
the Obama Administration's response as weakening, rather than
strengthening as promised. These include:
- Media coverage in The Wall Street Journal ("War on AIDS Hangs in
Balance as U.S. Curbs Help for Africa"), Newsweek ("AIDS Programs
Hit Setbacks in Africa"), The Boston Globe ("U.S seeks to Rein in
AIDS Program"), 60 Minutes and additional outlets describing a
"curb" in the US response to AIDS in Africa and the scaling back or
halting of AIDS treatment roll out in several African countries;
- A letter from nearly 300 physicians and scientists to House
Appropriations Committee Leadership characterizing the President's
FY11 budget as a "retreat" in the fight against AIDS; and
- A Congressional hearing convened by the House Foreign Affairs
Subcommittee on Africa and Global Health, investigating reports of
a halt in treatment enrollment in Uganda and elsewhere.
This memo provides background information and analysis regarding
the following critical developments in current U.S. policy on
global AIDS:
The FY10 and FY11 budget requests have included a flat-lining of
AIDS funding, and decreased funding for treatment, despite promised
increases. The FY11 budget requests a $50 million cut to the Global
Fund compared with the FY10 appropriation. When calculating real
funding available for bilateral AIDS-specific programming the FY11
budget requests roughly a 2% increase while inflation in Africa is
estimated at 7-10%. Overall funding for AIDS medicines has
decreased within PEPFAR, with some countries seeing 10%-15%
decreases in funding available for commodities each year.
Worrying signs of either outright halts or significant slowing in
PEPFAR treatment scale-up has been documented in Uganda, Nigeria,
Mozambique, South Africa, and elsewhere. In Uganda, hundreds people
are being turned away from AIDS treatment monthly while memos from
the U.S. government to implementers instruct additional enrollment
only where patients are lost to death or follow up. In Nigeria,
Mozambique, and South Africa rationing of care is evident, for
example with clinics forced to enroll only those who are severely
immune compromised--those with CD4 counts that are at 1/7th the
level recommended for treatment or rationing to only pregnant
mothers.
With new evidence showing the path to defeating the AIDS pandemic,
and AIDS as the leading killer of the women and mothers targeted by
the Global Health Initiative, the Administration is seen as
reversing successful trajectory. Key new scientific evidence has
shown prevention benefits of up to 90% for those on effective AIDS
treatment. Meanwhile, recent studies have shown AIDS to be not only
the leading killer of women ages 15-44, but the key reason progress
on maternal health in Africa has not been made. While the
Administration's well-received strategy focuses on building off of
PEPFAR's success, funding and policy decisions limiting treatment
will prevent success of the broader Global Health Initiative.
A. Administration Global AIDS Funding Levels and Policies Risk
Undermining Success
Campaign Promises and Supporting the Lantos-Hyde Act
Many global health, scientific, clinical, progressive, faith,
student, and people of color organizations applauded when
then-Senator Obama made bold commitments to tackle global AIDS and
followed through on those promises with bi-partisan legislation
passed just before the 2008 Presidential election. For example, on
World AIDS Day Senator Obama pledged to provide $50 billion by 2013
to fight the pandemic--increasing spending levels with $1 billion
in additional resources each year--and contribute the U.S. fair
share to the Global Fund, and backed this pledge with
legislation--co-sponsoring the Lantos-Hyde Act (along with Senator
McCain and then-Senators Clinton and Biden) that authorized $48
billion in spending by 2013. In addition, then-Senator Obama
promised to "continue to provide treatments to one-third of all
those who desperately need them."
Treatment Scale Up Substantially Less Than Promised
Currently an estimated 14 million people are in immediate need of
AIDS treatment, and that number is growing each year. Exciting new
science, discussed below, shows that reaching Universal Access (or
80% treatment coverage levels) could potentially turn the tide
against the epidemic--with infection rates, death rates, and the
financial costs of AIDS all falling as a direct consequence of
accelerated treatment scale up. This was why the Obama pledge to do
the U.S. share--treating 1/3 of those in immediate need--is
critical. At promised funding levels, between 6-10 million people
could be treated by 2013. Unfortunately, the new PEPFAR strategy
predicts only "at least 4 million" people on treatment by 2014.
This means adding 1.6 million more people over the coming five
years--roughly 400,000 per year--far fewer than the current rate of
treatment expansion and a number that does not keep pace with the
epidemic.
Funding Levels Flat-lined
Unfortunately, multi-year projections and yearly budget requests
signal this necessary--and promised--level of global AIDS funding
is not forthcoming.
The FY10 Administration budget request to Congress described--for
the first time since PEPFAR's inauguration--essentially
flat-funding U.S. global AIDS investments, with an increase of
roughly 2%. Congress added several hundred million dollars to the
President's FY10 request.
The Administration's FY11 budget request again proposed essentially
flat-funding global AIDS programs, including:
- $50 million cut from 2010 appropriated levels for the Global Fund
to Fight AIDS, TB, and Malaria
- only $180 million added to global AIDS care, treatment and
prevention (not including research)--with $100 million of that $180
million redirected into a new "Global Health Initiative Plus Fund,"
and therefore not available for AIDS treatment scale-up, according
to currently available information. This leaves only $80 million in
new funding for service delivery--a 1.5% increase. An $80 million
increase does not even keep pace with inflation, which is estimated
by the IMF to be approximately 7-10%.
Furthermore, the President's Global Health Initiative
(GHI)--welcomed with enthusiasm by many in the global health
community in principle--has neither sufficient funding nor the
policy choices needed to meet its stated goals, including those
related to AIDS. Specifically:
- GHI AIDS programming is framed as a six-year plan, rather than
the five authorized by Congress and promised in the presidential
campaign, but there is no additional funding for the sixth year;
- In a leaked 2009 presentation--the only publicly available
description of out-year budgets--the anticipated total increase is
$1 billion over 6 years, although Obama promised increases of $1
billion per year for AIDS.
- The total amount to be spent on AIDS over those 6 years--$37
billion--is less than the $39 billion anticipated in six years
under the PEPFAR Reauthorization by the Lantos-Hyde Act.
B. Evidence from the Field: Halting and Slowing AIDS Treatment
Scale up in Africa
PEPFAR funding shortfalls--and a response to HIV that is
de-prioritizing scale up of life-saving treatment--is resulting in
policy outcomes that are already having a grave impact on country
programs and on people with HIV in urgent need of treatment and
care. Here are recent examples:
PEPFAR has explicitly instructed partners to stop enrolling new
patients on HIV treatment: In Uganda, CDC wrote on October 29, 2009
to implementers: "PEPFAR Implementing Partners who directly provide
antiretroviral treatment should only enroll new ART patients if
they are sure that these new patients can continue to be supported
without a future increase in funding. . . . In filling treatment
slots that are made empty through attrition--i.e., deaths and loss
to follow-up estimated at 12-30% annually--priority should be given
to the sickest patients, eligible pregnant women, children, TB/HIV
patients, and family members of persons on ART [antiretroviral
treatment]."
In Nigeria, CDC has instructed implementers that expansion of
treatment is not allowable under current funding levels. Treatment
providers are concerned that turning away patients in need will
backtrack on years of work done to encourage people to get tested
for HIV.
PEPFAR sites are turning away new patients in clinical need of
AIDS treatment: For example, the Uganda-based Joint Clinical
Research Centre (JCRC), one of the earliest HIV treatment providers
in Africa, announced in March 2009 that they were not starting new
patients on treatment and that they could not guarantee support for
patients enrolled on treatment in the prior five months.
PEPFAR sites are rationing HIV treatment to only the sickest,
while waiting lists expand: Mildmay, one of the largest PEPFAR
implementers in Uganda, has a large and growing waiting list of
people in urgent need of treatment. They have shifted from
enrolling 260 patients on treatment per month to about 25 to
30--just enough to accommodate slots opening up due to patients
currently on treatment who are transferred out, die, default, or
are lost to follow up. Mildmay staff report that women and children
will suffer the most as a result of these restrictions because they
are least able to afford to pay out of pocket for treatment. Those
few patients being enrolled are only the sicker patients (<150 CD4
cells/mm3). Mildmay, like other providers, are unable to implement
new national treatment guidelines which were enacted to better
adhere to clinical knowledge and the revised World Health
Organization (WHO) recommendation to initiate ART enrollment
earlier in order to stave off opportunistic infections and increase
survival.
Right to Care (RTC), a PEPFAR implementer in South Africa, operates
170 AIDS care and treatment sites supporting 100,000 people living
with HIV. RTC recently told their sub-recipients to halt ART
enrollment. At issue was a radical change in policy: RTC and its
sub-recipients would only provide ART once the South African
government agreed to assume responsibility for the purchase and
provision of commodities. RTC estimated that in 2009 funding was
effectively reduced by 30%. Despite delays in government support,
RTC still prohibited sub-recipients from initiating any new
patients on treatment. One RTC sub-recipient, AIDS Care Training
and Support (ACTS), with approximately 3000 patients on treatment,
reported that only patients with CD4 count below 50 cells/mm3 and
pregnant women were considered exempt from the directive. As a
result, ACTS denied treatment to 60 treatment-eligible patients
each month from November 2009 through February 2010. In March 2010,
after four months, they were able to initiate new patients on
treatment, after signing a Memorandum of Understanding with the
government.
PEPFAR sites are reducing HIV testing: Over the last 6 months
Mildmay in Uganda has reduced HIV testing efforts in keeping with
the reduced provision of ART. Mildmay used to provide voluntary
counseling and testing to more than 320 clients four days out of
the week, they are now reduced to 120 tests and only on two days a
week.
PEPFAR and government implementers are filling partial drug
prescriptions because of the uncertain or insufficient funding:
Patients in some areas in Uganda are reporting government HIV sites
have shifted from providing three-month supply of ARVs, a critical
component of supporting good adherence, to just one month or even
requiring people to return to clinic from week to week, sometimes
at great cost and over a great distance. HIV positive patients in
Zambia at a PEPFAR clinic have reported getting only one-third of
their prescriptions filled. When one woman asked why, she was told
she "should be grateful she got anything at all" and that "next
month she may not get anything." Short-term supplies of medicine
undermine the perception that HIV treatment will be reliably
provided for patients when the need arises.
PEPFAR is spending less to save lives, and more on "technical
assistance": PEPFAR appears to be returning to an era in which US
foreign aid funded "technical assistance" instead of direct
services and the recurrent costs of AIDS treatment. Unfortunately
with such technical assistance comes a lack of commitment to
coverage targets and measurable impact. Without funding for
medicines, laboratory supplies and other essential commodities,
technical assistance has limited value. From FY08-FY09, PEPFAR
Focus Country treatment funding was cut 12%, from $1.56b to $1.38b,
the allocation for AIDS medicines decreased 17% (from $477m to
$394m) and the allocation for adult and pediatric AIDS services and
treatment decreased 12% (from $884m to $777m).
In Mozambique, USAID announced a budget cut for commodities from
10% to 15% annually over the next four years. It is unclear who
will step forward to take responsibility for the purchase of ARVs.
In the Democratic Republic of Congo, PEPFAR has replaced budget
lines dedicated to funds for medicines for opportunistic infections
and laboratory supplies, replacing these with funding for technical
assistance, sero-prevalence studies, and training. In this case,
Global Fund funding that was intended to expand treatment coverage
had to be reprogrammed to cover the costs created by PEPFAR's
budget cuts. This is a growing problem.
PEPFAR is proposing a decrease in US funding for the Global Fund,
while encouraging countries to rely more on the Global Fund for
financial support to maintain and expand treatment programs: the
Global Fund's resources are overstretched, in part due to the US
refusal to fully fund it. The Global Fund needs $20b over the next
three years (2011-13), $8.5b of which is for existing commitments.
The Global Fund's funding needs place at great risk proposals to
scale up treatment--and also place in jeopardy existing
initiatives. The Global Fund is expected to absorb the costs of
supplies previously funded by PEPFAR--instead of scaling up
treatment for new patients who are left with their treatment slots
in jeopardy.
PEPFAR is handing over responsibility for treatment provision and
scale-up to unprepared and unequipped governments: PEPFAR is
transitioning away from direct service provision in South Africa on
an unrealistic timetable, according to those familiar with the
situation. South Africa's national program is struggling to meet
the needs of world's largest population of people on ARVs and
people in need of treatment. In the Free State province, only about
one-quarter of those needing treatment have access and last year
people living with HIV in the province experienced a four-month
moratorium on treatment initiation due to lack of funding. The
Southern African HIV Clinicians Society estimated the moratorium
caused 3,000 deaths. In this precarious environment, one PEPFAR
sub-recipient ceased ART initiation in its clinics in the province
and no new organization was funded to take their place. Thus PEPFAR
required both continuing and new patients be transferred to the
public sector imminently. The organization's approximately 2500
continuing patients include 1000 transferred from the Department of
Health (DoH) during the moratorium because the DoH was unable to
subsequently retain them. According to the organization's program
manager: "It is like playing roulette. We had to wait for decrease
in patient load through natural loss to follow up in order to get
new patients on board, while always having to see how far our
budget will go every month."
In Nigeria, there are troubling early signs that PEPFAR intends to
cut its investments in HIV treatment over the next five years,
effectively "winding down" some HIV treatment programs regardless
of government lack of preparedness to take on a massive increase in
burden of patient care.
PEPFAR flat funding means missed opportunities to improve sub
optimal care: Major U.S. implementers have measured an increased
risk of mortality from later treatment initiation. In a large
cohort, AIDSRelief has found that patients starting treatment with
a CD4 count of under 50 cells/mm3 have a mortality that is 2.5 to
6 times that of patients starting treatment at a CD4 count greater
than 100 cells/mm3. Recently news reports indicate that PEPFAR's
director, Dr. Eric Goosby, is not going to implement new WHO
treatment guidelines to start treatment earlier--despite better
patient outcomes and long term cost savings associated with earlier
initiation. The messages from Washington suggest a return to the
chilling era of people with AIDS on the verge of death brought to
a clinic in a wheelbarrow--a common sight in the early phase of
treatment scale up.
Children with HIV and patients on second-line treatment are
falling through the cracks: The Clinton Foundation's HIV/AIDS
Initiative (CHAI), in partnership with UNITAID, has been procuring
pediatric and second-line ARVs for 40 countries, with the aim of
mainstreaming those procurement streams into the larger funding
streams represented by the Global Fund, PEPFAR and national
budgets. CHAI took on this responsibility because pediatric
populations and populations failing first-line medicines were
neglected, and with higher drug costs. However, due to the
challenging funding environment and limited growth in available
funds, national programs have found it difficult to transition
procurement responsibilities to these funding streams. As a result,
CHAI has had to request bridge funding from UNITAID for a
significant number of these countries, which would otherwise have
to resort to measures such as turning away or wait-listing eligible
patients. In several countries, it is likely that despite the
additional funding requested from UNITAID, which covers only a
small proportion of patients, current funding levels will not be
sufficient to meet patient demand.
Also, in some countries, the mechanism envisioned to reliably
transition patients from UNITAID and CHAI funding in the short-term
places at risk treatment scale-up for adult patients. For instance,
despite Zimbabwe's devastating disease burden, the scale-up of
adult patients is at risk in 2011 as PEPFAR and the Global Fund
resources must be used to retain coverage of pediatric patients
previously covered by UNITAID.
PEPFAR funding shortfalls have contributed to increased
volatility in national programs, with newly emerging drug stockouts
and instability of supply lines: For example, over the past 18
months, CHAI has observed the impact of the increasingly
challenging funding landscape for HIV across many of its 40
programs and partner countries. In several countries, short-term
funding gaps have been observed, partially as a result of the
fragmented funding architecture, but exacerbated by the overall
shortage of funding. In many countries, significant long-term
funding shortfalls are projected, and are beginning to have an
impact on the ability of national programs to meet the needs of
existing patients. Such shortfalls result in real and harmful
impact to patients, as clinics are forced to turn away eligible
patients, including family members of treated patients. In
addition, national programs are forced to make quality trade-offs,
such as limiting access to diagnostics services and delaying the
implementation of WHO guideline revisions which call for earlier
initiation of ART and a move to lower-toxicity drugs.
C. Ignoring the Science and Missing the Chance to End the AIDS
Pandemic
The Obama Administration is poised to scale back its commitment to
fighting AIDS in sub-Saharan Africa and the rest of the developing
world at the same time groundbreaking research indicates that
comprehensive access to effective HIV treatment is likely the most
powerful HIV prevention tool currently available and the best hope
for reducing the incidence of new HIV infections and ultimately
ending the HIV epidemic. The evidence shows:
- Antiretroviral therapy reduces HIV transmission in heterosexual
couples by more than 90%. A review of 14 studies reporting rates of
HIV transmission in sero-discordant heterosexual couples found no
cases of transmission where the HIV-positive partner on ART had
blood levels of HIV ("viral load") that were undetectable (<400
copies of viral load/mL). A study that followed 3,400 heterosexual
sero-discordant couples in seven African countries for one to three
years showed that access to ART was associated with a 92% reduction
in rates of new HIV infection. When viral load is controlled
through treatment, HIV is less likely to be transmitted.
- Antiretroviral therapy reduces HIV transmission at the population
level. HIV treatment was associated with a 53% reduction in new
HIV-positive diagnoses between 1997 and 2002 in Taiwan. New HIV
infections decreased by approximately 50% between 1996 and 1999,
coinciding with the introduction of HIV treatment in British
Columbia. And in San Francisco a substantial increase in HIV
testing and treatment between 2004 and 2008 was accompanied by a
decline in new HIV diagnoses, a decrease in the average viral load
in people living with HIV in San Francisco, and a decline in HIV
incidence of around one-third.
- Antiretroviral therapy reduces HIV transmission among people who
use injection drugs. Recent studies among injection drug users in
Vancouver have shown that, independent of other risk factors such
as unprotected sex and syringe sharing, the recent measure of
average viral load among HIV positive drug users was strongly
associated with an individual's risk of becoming HIV infected
during the period of 1996-2007. (Over that time period the use of
antiretroviral therapy rose from 42.5% to 69.6% among the study
cohort) Across British Columbia, researchers estimate that the
steady increase in HIV treatment coverage was associated with a 50%
decrease in new HIV infections diagnosed among people who use
injection drugs.
- Access to antiretroviral therapy for HIV-positive pregnant women
is key for ending transmission of HIV from pregnant women to their
babies. By 2015 cases of pediatric AIDS resulting from transmission
of HIV during pregnancy, delivery, or breastfeeding could be
virtually eliminated in sub-Saharan Africa--as it has been
virtually eliminated in most developed countries--if all
HIV-positive pregnant women have access to optimal HIV treatment
regimens. Despite these facts, PEPFAR implementers in some
countries are reporting the inability to ensure pregnant
HIV-positive women have access to quality combination therapy--in
part because of insufficient funding.
Over the preceding seven years, the U.S. has scaled up HIV
treatment in developing countries significantly. Now, the U.S.
appears prepared to squander that investment, and change
course--abandoning its commitment to ART scale up. Given promising
new data showing the public health imperative associated with
maximizing the preventive effect of HIV treatment, this troubling
policy shift could lead to millions of new HIV infections. Moreover
it will simply postpone--and likely increase--ballooning treatment
costs. Urgent course correction is needed--so that communities
benefit fully from the direct and indirect benefits of HIV
treatment, contributing ultimately to reduced rates of new HIV
infections, declining HIV prevalence, and--potentially--an eventual
end to the pandemic.
D. Threats to Women, Girls, and the Success of the Global Health
Initiative
The women and girls-centered approach of the GHI, and strengthening
of health systems, cannot be realized if the U.S. backtracks on its
global AIDS response.
- In Africa, HIV care and treatment is required to address women's
health: According to the WHO, HIV is the leading cause of death
globally among women of childbearing age. Data released last month
show that in Eastern and Southern Africa HIV has not only blocked
progress toward maternal health, but is responsible for an
additional 61,000 maternal deaths per year. Further, the rationing
of HIV treatment in the past has resulted in of the use of the
least effective PMTCT protocol (single-dose nevirapine) in
preventing transmission from mother.
- Flatlining spending ignores the importance of HIV treatment for
the health of children. HIV treatment for an infected mother has
been found to be strongly linked to the health of their uninfected
children. A study in Uganda found that ART roll-out was associated
with an 81% reduction in mortality in uninfected children, and an
estimated 93% reduction in orphanhood. A major killer of children
is orphanhood. A child who loses his or her mother is ten times
more likely to die because of lack of care. In 2008 UNAIDS
estimated a scaled phase-up to universal access to treatment by
2015 would result in a number of orphans that is approximately four
million below current projections. Further, stalling ART expansion
increases the vulnerability of young female children because they
are often the first to drop out of school and provide care for sick
or bedridden family members. Children's school attendance and
nutritional status tend to improve in households with access to
treatment.
- Insufficient treatment creates massive burdens on the health
system. Those without access to treatment flood the health systems.
HIV and tuberculosis also reduce the capacity of an already
strained health workforce. According to a WHO sponsored study, the
incidence of HIV in the Kenyan health workforce is twice the
national average, and death of health workers is the main cause of
attrition. On the continent as a whole, 43% of deaths or medical
retirement of health workers were known or suspected to be caused
by HIV, and 37% by TB.
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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