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Africa: Obstacles to AIDS Treatment
Nov 5, 2004 (041105)
(Reposted from sources cited below)
There is now a wide international consensus that providing AIDS
treatment to all in need of it is essential, along with prevention.
But the obstacles are substantial, including lack of resources but
also flawed policies and lack of political will. Among particular
barriers are the failure to make full use of generic drugs and the
policy of user fees that further restricts access.
This AfricaFocus Bulletin contains (1) a strong statement by the
Ecumenical Pharmaceutical Network, representing Christian medical
associations and hospitals in Africa, which calls on the U.S.
government to abandon its policy of insisting on U.S.-approved
brand-name drugs in its support for overseas AIDS programs, and
(2) an international call from AIDS professionals for a policy of
free access to a minimal package of care, including antiretroviral
drugs (ARVs) as well as other necessary measures. The "Free by 5"
statement requests additional individual and organizational
signatures by November 20. To sign on, see the contact information
In related actions, the Treatment Action Campaign in South Africa
again took the South African government to court yesterday, with a
renewed demand for transparency on the government plan to provide
AIDS treatment. See http://www.tac.org.za for the TAC statement and
Update: For several commentaries on the effects of the U.S.
election on U.S. policy towards Africa, see the Nov 4 issue of
Pambazuka News at
The bottom line: more of the same.
++++++++++++++++++++++end editor's note+++++++++++++++++++++++
A Statement of the Ecumenical Pharmaceutical Network (EPN) on the
President's Emergency Plan for AIDS Relief (PEPFAR)
Moshi, Tanzania, October 7th, 2004
Contact Ecumenical Pharmaceutical Network, Nairobi, Kenya
Tel: +254-20-4444832/ 4445020; Fax: +254-20-4445095/4440306
Email: email@example.com; Website: http://www.epnetwork.org
The Ecumenical Pharmaceutical Network (EPN), comprised of Christian
Health Associations and hospitals, non-profit drug supply
organisations and church related development agencies, from 22
countries attending our Annual General Meeting held from 5th - 7th
October 2004 in Moshi, Tanzania issues this statement on the US
President's Emergency Plan for AIDS Relief (PEPFAR).
We recognise and acknowledge that scaling up medical assistance and
the care of the men, women and children in our communities who are
infected and affected by the scourge of HIV/AIDS, must continue.
Therefore, we welcome the initiative and the goals of the US
emergency response to provide much needed resources for HIV/AIDS
care and support; increase the number of patients under treatment;
and, contribute towards the improvement of infrastructure required
to fight HIV/AIDS. This gives hope for people living with HIV/AIDS.
However, as a network of health care service providers, we express
our deep concern over some aspects of PEPFAR which have been
identified as generally applicable, but to varying degrees in
individual beneficiary countries:
- PEPFAR's insistence on FDA approval for all medicines purchased
and the 'buy American' requirement for medicines other than ARVs,
causes needless delay in making life-saving drugs available and may
be inconsistent with national treatment protocols.
- PEPFAR's overwhelming preference for brand-name drugs and the
barriers to the use of more affordable generic ARVs and drugs for
opportunistic infections raise four major concerns:
- It introduces a situation where patients are given different
brands of the same drug thus creating a multi-cadre patient system
in an institution, leading not only to misunderstandings but also
a lot of additional work for an already overstretched health staff.
- It will be difficult for the institutions to continue providing
the same treatment at the end of the PEPFAR programme.
- Using drugs approved only by the FDA may kill the local
industries and threaten the sustainability of the already existing
drug supply chains. This is particularly true of drugs against
opportunistic infections, which are produced locally at affordable
- Use of expensive branded products, where equally good but cheaper
alternatives are available, is not a cost effective use of
- In some cases, PEPFAR disregards national drug regulations and
local supply chain management systems, which could damage national
health systems, especially the pharmaceutical sector.
- Treatment requires a lifetime commitment, yet there is currently
no long-term strategy to provide a continuance of care at the end
of the programme. The high level of donor control and little or no
country or local ownership further undermines the sustainability of
health care and other services.
- In its current form, the implementation of PEPFAR promotes
extensive use of US skills and capacities (personnel and
institutions) to the detriment of available local expertise with
greater understanding of the issues in their local contexts.
- There is excessive delay caused by the inherent bureaucracy and
conflicting operational rules and regulations. Cumbersome and time
consuming documentation requirements; complicated procurement
procedures for drugs and other needed items and restrictive
expenditure regulations, frustrate and undermine the efforts of
institutions trying to implement PEPFAR.
- The implementation of PEPFAR is predominantly unilateral,
undermining other international efforts such as the '3 ones' (one
co-ordination, one strategy and one monitoring/evaluation) and the
UN Prequalification Project managed by WHO.
In light of the above, we make the following recommendations:
- PEPFAR should remove the restrictions of its funds to purchase
only medicines approved by the FDA and the 'buy American' clause
and instead allow the purchase of nationally approved medicines,
generics or brand-name drugs, and antiretrovirals pre-qualified by
- PEPFAR should address fears of local drug management and supply
institutions that they will be harmed by PEPFAR, and commit to
strengthen and improve local structures and systems.
- PEPFAR should hold extensive consultations with local partners
in all areas of the programmes including policy formulation,
planning, design, preparation of terms of reference and actual
- PEPFAR should regularly meet with community constituted advisory
and oversight bodies comprised of people living with HIV/AIDS,
FBO's involved in medical delivery, and health care experts among
- Immediate discussions should start between PEPFAR, other donors,
governments and implementing partners on the sustainability of
services beyond 2008.
- PEPFAR should actively identify and involve local experts
resident in the partner countries for the effective implementation
- PEPFAR should dialogue with local implementing partners with a
view of recognising and accepting available and relevant local data
or data collection systems and the simplification of documentation
- PEPFAR should co-ordinate more effectively with existing
international HIV/AIDS programmes including the Global Fund and the
WHO '3 x 5' to ease implementation and avoid duplication at local
We the members of EPN, in the spirit of goodwill and solidarity,
further affirm that the fight against HIV/AIDS deserves concerted
effort from all partners to ensure sustainability, effective use of
resources, expanded local capacity, empowerment of people living
with HIV/AIDS and provision of treatment for as many people as
possible. In view of the above, we commit ourselves to play our
part in making sure that the PEPFAR programme is implemented to the
best interest of those served, the implementing partners and the
This statement has been signed on behalf of Ecumenical
Mr. Albert Petersen, Chair EPN Board
Dr. Eva M A Ombaka, Coordinator EPN
Free by 5: International Sign-on Statement in Support of Free AIDS
From: Gorik Ooms, MSF-Belgium firstname.lastname@example.org
HIV/AIDS treatment including anti-retroviral therapy is
increasingly available throughout the developing world. However,
the drugs and associated laboratory tests are rarely provided for
free. Most people living with HIV will die simply because they
cannot afford the contribution which is sought from them.
There is evidence that user-fees for AIDS treatment are barriers to
equity, efficiency and quality of treatment programs. They threaten
the possibility of scaling up these programs.
We believe that, for human rights, public health and economic
reasons, there should be free access for all to a comprehensive
minimum medical package, including ARVs.
Faced with the emergency and gravity of the situation, people from
HEARD, IRD, MSF-Belgium and others have developed the 'Free by
Five' declaration to emphasize the necessity of free treatment.
The ultimate objectives of the Free by 5 Declaration are:
provide economic and public health evidence that could help inform
the decisions of policy makers and governments on the issue of free
b.. to urge UNAIDS, WHO, the Global Fund, the World Bank, PEPFAR
and other donors to adopt guidelines and actively promote the
principle and implementation of free treatment;
c.. to assist activists and others in their advocacy efforts to
obtain free treatment.
We are asking for your commitment to the principle of free HIV/AIDS
treatment. Please sign the "Free by 5" Declaration.
If you wish to sign the declaration please:
1.. Send an email to Sabrina Lee (Freeby5@hotmail.com) before the
November 20th deadline;
2.. State your name, position, organization and contact details;
3.. Indicate whether you sign on behalf of your organization or as
The first signatories of the declaration include: Stephen Lewis, UN
Special Envoy for HIV/AIDS in Africa; Alice Desclaux, M.D.,
Professor of Anthropology and Director of Research Center on
Culture, Health and Societies (CReCSS), University Paul C‚zanne,
Aix-Marseille, France; Helene Rossert-Blavier, Director of Aides
(France), Vice-President of the Global Fund to fight AIDS,
Tuberculosis and Malaria; Gorik Ooms, Executive Director, MSFBelgium;
Bernard Taverne, Anthropologist, M.D., Institut de
Recherche pour le Developpement, Dakar, Senegal; Alan Whiteside,
Professor and Director of Health Economics and HIV/AIDS Research
Division (HEARD), University of KwaZulu-Natal, Durban, South
Africa; and Nicoli Nattras, Professor of Economics and Director of
Centre for Social Science Research, University of Cape Town, South
Signatories will be updated regularly on the website
http://www.heard.org.za where the declaration is available in
English and in French. The declaration will be launched at a series
of events at the end of November 2004.
We look forward to receiving your support,
Free by 5
Economists', public health experts' and policy makers' declaration
on free treatment for HIV/AIDS
[Excerpts from statement. For full statement, including footnotes
and answers to counter-arguments, visit http://www.heard.org.za]
We, economists, public health experts and policy makers involved in
the fight against AIDS are committed to scaling up access to
healthcare, including ARVs, for HIV positive people with the
objective of universal access. We consider it a rational economic
decision and an absolute priority.
We believe that a prerequisite for ensuring that treatment programs
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.
We believe that the treatment package should include HIV tests,
prophylaxis and treatment of opportunistic infections, all
laboratory and associated examinations, consultation and
hospitalisation fees, and ARVs.
We argue that WHO, UNAIDS, the governments of resource-poor
countries and international donors, among them the Global Fund, the
World Bank, PEPFAR and bilateral cooperation agencies, must adopt
and actively promote the principle of universal free access to
treatment (including ARVs) and contribute to its implementation.
We urge that additional resources be mobilized through long-term
commitments. These should come mainly from donor funding, with the
contribution of other stakeholders. Governments in resource-poor
settings should engage in an appropriate allocation of domestic
resources to show commitment to achieving this goal.
We are committed to promoting the principle of free treatment, and
to contributing to its implementation. Otherwise, the idea of
universal access will remain a dream.
There is consensus on the necessity of providing healthcare in
general, and ARV programs in particular, for HIV positive people in
In June 2001, the United Nations General Assembly Special Session
on HIV/AIDS unanimously adopted a Declaration of Commitment
recognizing that: "effective prevention, care and treatment will
require behavioural changes and increased availability of and
non-discriminatory access to (...) drugs, including anti-retroviral
therapy, diagnostics and related technologies".
Treatment is justified on economic grounds and for human rights
reasons. If we fail to provide it, societies face catastrophe.
The goal set by WHO is to have 3 million people on treatment by the
end of 2005. There are, of course, major concerns around the
scaling up of access to treatment. What it will cost, who will do
it and how it will be done are still being debated, and we have
much to learn. How can these programs improve the uptake? How can
they reach the most vulnerable and poor populations? How can they
achieve a high level of adherence to ARV treatments in order to
We are faced with many uncertainties but we also have some
evidence. This declaration sets out a principle we all should
subscribe to and apply: the principle of a comprehensive minimum
package of treatment provided free to all the people living with
The current situation: many patients are being asked to pay for
their treatment. ... in the vast majority of resource-poor
countries, access to treatment is not free.
In Senegal, ARVs, CD4 counts and viral load tests are free, but
other laboratory exams required to initiate therapy have to be paid
for and are a major obstacle to access to ARVs. Laboratory exams
and drugs for opportunistic infections are not free either. People
who would qualify for free drugs cannot afford the tests to obtain
them and may die of opportunistic infections despite the fact they
have free access to ARVs.
In other countries ART is heavily subsidized, but a monthly
contribution is sought from patients: in Burkina Faso patients are
expected to contribute 8,000 FCFA per month (12 euros); in Cameroon
the current cost for the patient is between 15,000 and 28,000 FCFA
(between 23 and 43 euros); and Niger, in its proposal presented
to the Global Fund, will have a range of contributions from 8 000
FCFA (12 euros) to 75,000 FCFA (114 euros) according to the
The cost of drugs for opportunistic infections, laboratory exams,
consultations and hospitalisation fees must be added to these
A study in Senegal assessed the cost to patients and found that
those on ARV treatment had to pay an average of 5,200 FCFA per
month (7,9 euros), i.e. 95 euros per year for their medical
expenses additional to the cost of ARVs. ...
These examples give an idea, however imprecise, of the burden of
medical expenses on the patients' and their families' finances.
Why do we need free treatment?
There is evidence that user fees in healthcare pose a wide variety
of problems, which will worsen in the case of HIV. Therefore, there
are many reasons for the provision of free HIV/AIDS treatment:
among them are public health and ethical arguments.
In order to reach a large number of people, most of them living
below the poverty line, and to achieve the 3 x 5 goal, treatment
will have to be free. It is unrealistic to believe that treatment
programs can be scaled up otherwise. Free treatment is a
prerequisite for the achievement of universal access.
Research shows that even when the contribution sought from the
patient for ARVs is small, some are excluded because they cannot
afford it. Therefore, providing free treatment will help poor
people to have access.
We are fully aware that giving free access to HIV treatments will
not be sufficient to achieve equity in these programs, and far more
needs to be done. In particular, the needs of the most vulnerable
groups must be addressed. But providing treatment free of charge is
a necessary condition for the achievement of equity.
Research in Senegal shows the main reason patients were not
adherent was that financial problems led to treatment
interruptions. In Kenya, patients have discontinued ARV treatment
due to lack of money. Adherence must be high in order to avoid
resistance and ensure long-term benefit for the patient. Providing
treatment for free will contribute to adherence.
Moreover, free treatment is the best way to reduce demand for
antiretroviral drugs on the informal market, misuse and consequent
viral resistance and to minimize the number of people lost to
follow up. Finally, paying for care causes delays in health seeking
when, ideally, HIV patients should come at the early stage of
illness to optimize the outcome of treatment. Providing treatment
for free will contribute to adherence and efficiency at the
individual and population level.
The poor are the majority
In resource-poor settings the poorest are not a minority! In
Senegal, 60% of the population lives below the poverty line; in
Botswana, it is 50,1% of the population, in China 47,3%, in India
79,9%, in Ivory Coast 49,4%, in Nigeria 90,8%, and in Uganda 96,4%.
If the vast majority of the population is eligible to free
treatment, what is the rationale for exemptions that will be costly
to put in place and administer?
Exemptions or waivers systems are not cost-effective
Finally, the process of defining who gets free treatment and who
will not is a resource-consuming process. It takes time, money and
personnel, and the amount of money collected is usually not worth
For all these reasons we believe that treatment should be provided
free of charge to all people living with HIV and AIDS, regardless
of their socio-economic status.
What is to be made free?
If treatment is to be free then more than drugs are needed. The
question of what is to be made free is a big issue, and needs
further research, reflection, and international guidelines. At this
stage, we propose a minimum package that should be made available
free through the public healthcare system.
This should include:
- HIV tests
- Consultations with medical staff
- Laboratory examinations (according to WHO medical guidelines or
to national medical guidelines if they are more extensive)
- Treatment of common opportunistic infections
- Prophylactic treatment
Who will pay for it?
The total cost of providing treatment through the 3 by 5 initiative
alone ranges from $5.4 to $6.4 billion for the two years 2004 and
2005. UNAIDS estimates that the amount of money needed for
treatment and care in 2005 is $3.8 billion, and this will increase
to $6.7 billion in 2007. The amounts at stake will not change if
free treatment is implemented.
Patients' contributions are marginal in the overall cost of
programs because their ability to pay is very limited in a context
of generalized poverty. Therefore the implementation of free
treatment will not dramatically change the level of contributions
asked of other stakeholders (donors, governments, etc).
Financing the response to HIV/AIDS is an enormous challenge, but it
will not be heightened by the provision of free treatment.
We note with great concern that the funding gap involved in
providing a comprehensive package of care through the 3 by 5
initiative was over $2.5 billion for 2004-2005 as of December 2003,
and will increase in the years to come. Therefore we urge
international donors, and other stakeholders to fund the minimum
package through long-term commitments.
We further expect resource-poor countries to make the appropriate
contribution. In April 2001, African leaders meeting in Abuja
committed themselves to allocating 15% of their public expenditure
to health. ...African leaders have endorsed these policy statements
and must ensure they are implemented.
All stakeholders have the responsibility to work in partnership to
ensure the provision of free treatment.
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