The AIDS treatment era - the rollout of ART
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 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.
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.
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 IRIN. "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 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 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 IRIN. - [IRIN]
More information:
For more articles on the subject, plus interviews and a comprehensive
database on numbers on treatment in sub-Saharan Africa, visit the PlusNews
Web Special http://www.plusnews.org/webspecials/ARV/default.asp/
[This Item may not necessarily reflect the views of the United Nations. Copyright (©) UN Office for the Coordination of Humanitarian Affairs 2004]
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