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Africa: AIDS Time Bomb

AfricaFocus Bulletin
Oct 18, 2004 (041018)
(Reposted from sources cited below)

Editor's Note

"If we think we are seeing an impact today, we have to brace ourselves because it is set to get very much worse." Alan Whiteside of the United Nations Commission on HIV/AIDS and Governance in Africa (CHGA) issued this warning last week at a meeting of the commission in Addis Ababa. Scaling up of treatment is now on the continental and global agenda. But the pace is still far short of that needed to stem the drop in life expectancies and catastrophic damage to all sectors of societies.

There is now agreement in principle that treatment is both essential and possible. But, as Commission patron Pascoal Mocumbi stressed to the gathering, the loss of teachers, health workers, and civil servants is itself among the key factors undermining the capacity to fight back.

This AfricaFocus Bulletin includes a press release from the Economic Commission on Africa reporting on the CHGA meeting. It also excerpts a background paper prepared for CHGA, which provides a clear summary of current opportunities and obstacles.

For previous issues of AfricaFocus Bulletin on this topic, see http://www.africafocus.org/healthexp.php

Other key recent documents include:

(1) a call from the World Health Organization on the urgency of focusing on the interaction between treatment of TB and HIV/AIDS http://www.who.int/mediacentre/news/releases/2004/pr66/en

(2) the most recent issue of the Global Fund Observer, at http://www.aidspan.org/gfo/archives/newsletter/GFO-Issue-32.htm

and

(3) the revamped Global Fund website, with news on recent contributions by Sweden and the Netherlands, and reports on both contributions and country programs, at http://www.theglobalfund.org

++++++++++++++++++++++end editor's note+++++++++++++++++++++++

Economic Commision for Africa

Africa's Future Depends on Treatment for People Living with HIV, AIDS Commissioner Warns

ECA Press Release No. 25/2004

Issued by the ECA Communication Team P.O. Box 3001 Addis Ababa Ethiopia Tel: +251-1-44-58-26 Fax: +251-1-51-03-65 Email: ecainfo@uneca.org Web: http://www.uneca.org

Addis Ababa, 14 October 2004 (ECA) The former Prime Minister of Mozambique, Pascoal Mocumbi, has warned of devastating consequences for Africa if HIV-positive people are not given treatment.

"The very future of our societies is tied to keeping these people alive," he told hundreds of delegates at the African Development Forum in Addis Ababa, Ethiopia.

"There is no escaping the fact that the loss of teachers, health workers and civil servants at the rates witnessed today threatens deterioration and eventual collapse," he said. "The cost of writing off HIV-infected people is too high to contemplate."

Mr Mocumbi was giving a preview of the likely findings of the Commission on HIV/AIDS and Governance in Africa that is due to report to UN Secretary General Kofi Annan in June 2005.

Mr Mocumbi is a patron of CHGA, as is former President of Zambia, Kenneth Kaunda.

He said that there are still gaps in knowledge of HIV's impact on governance, particularly on the skills base in all sectors of society even though such knowledge was vitally needed.

"We have little or no information on the ramifications of mortality amongst senior government officials What effects are such losses having on the delivery of public services, economic development and national security?" he asked. "At what point might institutions or states as a whole simply cease to function?"

Mr Mocumbi said CHGA's work would help governments understand the impact of AIDS on human capacity and related planning and budgetary implications.

He called on governments to rethink their growth and development strategies taking HIV/AIDS into account. "There is no evidence that any country has begun to address comprehensively the human resource planning challenges raised by the HIV epidemic," he said.

CHGA aims to provide governments with practical recommendations on up-scaling prevention, treatment and care programmes who need it. Mr Mocumbi acknowledged that extending the lifespan of the HIV-infected remains Africa's greatest challenge.

Media Advisory

The Commission on HIV/AIDS and Governance (CHGA) CHGA is chaired by the Executive Secretary of the Economic Commission for Africa, K.Y. Amoako and was set up in 2003 to consider the long-term impact of the AIDS pandemic on Africa and make recommendations. It concluded its third meeting on Wednesday evening, 13 October 2004. The two CHGA patrons and 13 commissioners were present, including Peter Piot, Richard Feachem, Bassare Toure and Paulo Teixeira.

Members of the Commission Thursday morning addressed a plenary session of the African Development Forum hosted by the UN Economic Commission of Africa at its conference centre in Addis Ababa, Ethiopia, to report back on their meeting and give a preview of what will be contained in the final CHGA report in June 2005.

On Monday October 12, over one hundred Ethiopian civil society members including NGO representatives, policy makers and UN agencies from across Africa met in a "CHGA Interactive" session to discuss the impact of HIV/AIDS on rural communities and on food security.

The meeting discussed key challenges such as the burden of increased health care costs, failing rural safety nets; and the problems of elderly caregivers and foster parents. Those present called for a holistic response encompassing prevention, mitigation strategies and increased access to treatment and care.

For more information on the Commission on HIV/AIDS and Governance in Africa, please contact: Fabian Assegid, Tel: +251-1-445066 or 445408, Email: fassegid@uneca.org.

The fourth African Development Forum was opened Monday 11 October 2004 in Addis Ababa by Ethiopian Prime Minister, H.E. Meles Zenawi. Details of the opening session, audio and video clips, speeches, documents and the programme can be found at http://www.uneca.org/adf/


Scaling up AIDS treatment in Africa: issues and challenges

Background paper for CHGA Interactive

Gaborone, Botswana 26-27 July 2004

Economic Commission for Africa Commission on HIV/AIDS and Governance in Africa

[Excerpted. For full text of this and other publications, see: http://www.uneca.org/CHGA]

...

Introduction

In 2004, it is estimated that 25 million people live with HIV/AIDS in Sub-Saharan Africa, and the number is increasing rapidly. As well as a harrowing catalogue of lives lost, the implications of this human tragedy reach into the structure of economies, the capacity of institutions, the integrity of communities and the viability of families. In the extreme, the survival of some states may well be called into question. Already, communities across large parts of the continent are facing a day-to-day reality of declining standards of living, reduced capacities for personal and social achievement, and an increasingly uncertain future.

While prevention undoubtedly plays an important role in stemming the epidemic, supporting those already infected in living healthier, longer lives is crucial to minimizing the impact of the epidemic, and the two need to advance in parallel. Until recently, life-prolonging treatment was available only to a tiny fraction of HIV-positive people in Africa. High costs, a demanding treatment regime and the lack of even a basic health infrastructure to deliver the treatment were cited as insurmountable barriers to providing treatment to Africans who needed it. Over the last two to three years, this perception has gradually changed. Four interrelated developments have helped to change this perception:

1. The emergence of a simpler treatment regime

In 1998, the typical daily intake for an individual on antiretrovirals was between six and fifteen pills per day. Today, it can be as little as between two and three per day, as drug makers, particularly producers of generics, have been able to combine several pills into one.

2. The dramatic drop in the cost of ARVs

When ARVs were introduced in the early 1990s, they were hugely expensive. Since then, they have dropped. In the last few years, the price of treatment in particular first-line treatment has fallen very quickly, from around US$10,000 to US$ 200 per patient per year. Although still beyond the price reach of ordinary people, the general trend is for ARV prices to decline further. This remarkable achievement is a result of a complex process combining negotiations between the major pharmaceutical companies, UN organizations, governments, NGOs and competition from generic producers.

3. Agreement on a medical treatment protocol for resource-limited settings

Over the past three or so years at least a dozen pilot treatment programmes implemented by numerous actors have helped develop and form consensus around an appropriate treatment protocol for resource limited settings. Although there are still some medical issues to be further improved and clarified, such as pediatric treatment protocols, the usefulness of structured treatment interruptions, and the efficacy of immune boosters such as vitamins - the general results from the existing pilot studies are very encouraging. Crucially, they show that adherence and treatment results are equal to those in the developed world.

4. Increased international funding for Anti-Retroviral Treatment (ART) for low-income countries.

In June 2001, a watershed was reached when the United Nations General Assembly Special Session (UNGASS) on HIV/AIDS unanimously adopted a Declaration of Commitment recognizing the need for implementing national strategies to address factors affecting the provision of HIV-related drugs. The creation of the Global Fund to fight AIDS, Tuberculosis and Malaria has been a significant indicator of the international commitment for financial support for health related issues in Africa. Among numerous other players on the international scene, the World Bank, the Bill and Melinda Gates Foundation and President Bush's initiative are devoting significant resources to the cause of AIDS treatment in Africa. As a result of these crucial developments, the international climate of opinion has now shifted firmly in favor of sharply expanding HIV/AIDS treatment in Africa. In 2002, the World Health Organization, along with other UN agencies committed themselves to the goal of providing access to ART for 3 million people before the end of 2005. In addition, African governments have increased their own commitment to fighting the epidemic, including through provision of treatment.

Challenges to scaling up treatment in Africa

Progress in scaling up has not kept pace with increasing demands for HIV-related treatment. It is estimated that only 400,000 HIV-infected persons in the developing countries currently receive ARVs of any kind about half of them in Brazil alone. The World Health Organization estimates that there are currently 100,000 people on antiretroviral therapy (ART) in Sub-Saharan Africa, a coverage of only 2%, whilst over 4.4 million people remain in need of immediate treatment on the continent. The first funding commitments by the Global Fund made in 2002 has allow a two-fold increase in the total number of individuals receiving ART in developing countries, and a six-fold increase in Africa in the last few years. In spite of the noted advances, the challenge of scaling up from current initiatives to the comprehensive treatment programmes needed in Africa will pose significant logistical and support problems. ...

Health System Capacity

In the African context, limited human as well as financial resources in poorly developed health care infrastructures represent major barriers to scaling up treatment provision. The main barriers are:

a.Human Capacity: Low and declining number of health professionals

An immediate imperative is to stabilize and replenish the existing human resource base that provides health care in Africa. In many countries, that base is under siege. Health providers themselves are getting sick at high rates, and many who are healthy are migrating out in search of economic betterment. Furthermore, ART requires close supervision and monitoring of the patient compliance to treatment. This requires substantial work-time from medical staff. There is a clear need to train more doctors, nurses and other health personnel, but also to improve motivation, working environments and incentives. Tackling issues such as low remuneration and poor benefits, insufficient infrastructure, and lack of opportunities for career development, is a prime challenge in preventing migration of health professionals and improving an enabling environment for AIDS treatment and care.

Pilot projects have shown that some tasks related to ART such as routine followups and counseling can be carried out by lay community workers, properly trained and supported by referral systems. Scaling up ART therefore also poses the challenge of training and managing more community workers to ease the burden of medical personnel.

b. Financial Capacity: Cost reductions and fiscal sustainability

Costs of ARV drugs have declined substantially, but the price is still prohibitive for most Africans. Take the example of Kenya, where even under the best-case scenario of ARV drugs becoming available at $1 per day, they would cost 100% of the average monthly income of $30. At the national level, treating 25% of all HIV infected individuals in Kenya would cost 6.3% of GNP, more than seven times the current government spending on health. For scaling up to be successful, the price of ART and related interventions will need to come down to the level where African governments can budget for them in a sustainable manner.

A number of recent international initiatives provide funding for scaling up AIDS treatment in Africa. Key initiatives for AIDS treatment in Africa such as the Global Fund for AIDS, Tuberculosis and Malaria, the Bill and Melinda Gates Foundation and President Bush's AIDS Initiative represent very positive developments, but have a limited life span. A challenge for governments is that once started, ART must to be provided for the patient's lifetime. When the international funding dries up, governments need to find a way to foot the bill. ...

Another challenge for a number of African governments is to increase absorptive capacity to appropriately funnel the additional funding through the public expenditure framework. A major obstacle to this is posed by maximum levels (or 'ceilings') on public spending imposed by international financial institutions such as the International Monetary Fund (IMF), in order to safeguard macroeconomic stability. As a result, countries have found themselves unable to accept additional funding for HIV/AIDS. This issue needs to be addressed in a consistent manner. In addition, governments are required to expand their absorptive capacity to enable utilization of increasing external funds for health.

In any case, cost considerations of treatment should not hinder the promotion of treatment. The provision of treatment is, ultimately, a cost-saving strategy. The benefits of providing treatment through averted hospitalization costs, the social benefits in terms of maintaining household cohesion and saving children from orphanhood, and the economic benefits of maintaining the workforce, are estimated to exceed the financial costs of providing treatment by far.

c. Inadequate laboratory and patient care infrastructure

ART is a complex process which requires close surveillance by care providers, careful adherence to the therapeutic regime, and access to laboratory facilities for continual testing so that the therapy regime can be adjusted. All of these facilities must be available if ART programmes are to be undertaken successfully. In a recent Kenyan study, for example, it was shown that whilst doctors throughout the country were prescribing antiretroviral drugs, only 30% of these doctors had received any training in administering and monitoring ART, and outside Nairobi, no laboratory facilities were available for monitoring the progress of therapy.

d. Poor patient follow-up leading to low adherence

Patients must take ARVs on a regular basis. If random interruptions occur, the virus is likely to mutate into drug-resistant strains. Lack of adherence to treatment is not a new problem. For example, the emergence of multi-drug resistant tuberculosis (TB) is related to lack of adherence to TB treatment. ART, as a lifelong, complex and time-demanding treatment, complicates adherence. This is compounded by the stigma surrounding AIDS, forcing some patients to follow the treatment secretly. Close patient follow-up has shown to increase adherence, but this is a challenge in resource-constrained African settings.

e. Sustainable drug supply

A discontinuation in drug supply increases the risk of treatment failure. This is not only detrimental to the patient, but also facilitates the emergence of drug resistant strains of the virus. Periodic drug shortages are not uncommon in Africa, as for example the shortages denounced by MSF and WHO in Kenya in 2003. The challenge at the national level is to build strong drug procurement and distribution systems, avoiding supply interruptions as well as leakages of drugs, and ensuring drug quality. At the project level, logistics are also crucial, including mechanisms to ensure safe drug storage and distribution.

Fostering Stakeholder Buy-in

Successful scaling up of treatment does not only require adequate health care infrastructure, but also commitment and leadership at all levels.

a. Private sector, NGO and FBO involvement

Currently, both the private sector, NGOs and Faith-Based Organisations (FBOs) (including mission hospitals) have been in the front line of treatment provision in Sub-Saharan Africa. As ART is increasingly also made available through public health care systems, efficient coordination and harnessing of the whole spectrum of providers will be crucial. The growing role of the private sector calls for stronger regulation by the government in order to ensure quality and equity of services.

b. Community involvement

Community involvement is crucial to scaling up treatment, for three main reasons. First, communities are instrumental in fighting against stigma and advocating for treatment. Second, their involvement is key in identifying eligibility criteria for treatment. Third, communities are also required to care and support for the infected individuals and affected families. Already strained by multiple demands, communities in the hardest-hit areas are struggling to cope. ...

c. Ensuring equitable access to treatment and care

Access to treatment and care is a human right. However, in contexts where the need for treatment exceeds the available supply, health care providers have to tackle the difficult question of who gets access to life-saving services and why. For example, in the context of wide-spread gender discrimination, more men than women would be able to access treatment in the absence of intervention to ensure more equitable service distribution. Human rights, law and ethics provide guidance to expanding services in a just and equitable manner. ... Experience on prioritization in resource-limited settings is evolving. Botswana, for example, first targets patients with tuberculosis, and HIV-positive women and their spouses and infants. Medecins Sans Frontieres (MSF) in South Africa establishes eligibility based on biomedical adherence and social criteria.

d. Need to overcome stigma.

One of the first lessons from the "Masa" programme in Botswana is that significantly fewer people than expected were coming forward for testing despite the availability of free treatment. Furthermore, many of those who came were in the very advanced stages of the disease, when the ART failure rates are higher. Misinformation, stigma and fear of discrimination are probably key factors discouraging people to come forward for testing and treatment. Much more therefore needs to be done to overcome the cultural constraints to treatment.


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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