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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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