[Peace-discuss] Fwd: Africa: Obstacles to AIDS Treatment

[Alfred Kagan]

>To: akagan at uiuc.edu
>Subject: Africa: Obstacles to AIDS Treatment
>From: africafocus at igc.org
>Sender: World Wide Web Owner <www at africafocus.org>
>Date: Fri, 05 Nov 2004 07:23:28 -0800
>
>
>Africa: Obstacles to AIDS Treatment
>
>AfricaFocus Bulletin
>Nov 5, 2004 (041105)
>(Reposted from sources cited below)
>
>Editor's Note
>
>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
>below.
>
>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
>other background.
>
>++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
>
>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 http://www.pambazuka.org/index.php?issue=181
>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: epn at wananchi.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:
>
>1. 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.
>
>2. 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
>prices.
>
>* Use of expensive branded products, where equally good but cheaper
>alternatives are available, is not a cost effective use of
>resources.
>
>3. In some cases, PEPFAR disregards national drug regulations and
>local supply chain management systems, which could damage national
>health systems, especially the pharmaceutical sector.
>
>4. 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.
>
>5. 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.
>
>6. 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.
>
>7. 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:
>
>a. 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
>the WHO.
>
>b. 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.
>
>c. 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
>project implementation.
>
>d. 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
>others.
>
>e. Immediate discussions should start between PEPFAR, other donors,
>governments and implementing partners on the sustainability of
>services beyond 2008.
>
>f. PEPFAR should actively identify and involve local experts
>resident in the partner countries for the effective implementation
>of activities.
>
>g. 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
>requirements.
>
>h. 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
>level.
>
>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
>funding agency.
>
>This statement has been signed on behalf of Ecumenical
>Pharmaceutical Network.
>
>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
>Treatment
>
>From: Gorik Ooms, MSF-Belgium gorik at tiscali.be
>
>Dear friends,
>
>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: a.. to
>provide economic and public health evidence that could help inform
>the decisions of policy makers and governments on the issue of free
>treatment;
>
>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 at 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
>an individual.
>
>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 CÈzanne,
>Aix-Marseille, France; HÈlËne Rossert-Blavier, Director of Aides
>(France), Vice-President of the Global Fund to fight AIDS,
>Tuberculosis and Malaria; Gorik Ooms, Executive Director, MSF-
>Belgium; Bernard Taverne, Anthropologist, M.D., Institut de
>Recherche pour le DÈveloppement, 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
>Africa;
>
>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,
>
>Gorik
>
>*************************************************************
>
>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.
>
>Introduction
>
>There is consensus on the necessity of providing healthcare in
>general, and ARV programs in particular, for HIV positive people in
>resource-poor settings.
>
>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
>avoid resistance?
>
>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
>HIV/AIDS.
>
>...
>
>
>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)[11]; 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
>patient's income.
>
>The cost of drugs for opportunistic infections, laboratory exams,
>consultations and hospitalisation fees must be added to these
>contributions.
>
>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)[12], 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.
>
>Uptake
>
>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.
>
>Equity
>
>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.
>
>Efficiency
>
>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
>it. ...
>
>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)
>* Hospitalisation
>* Treatment of common opportunistic infections
>* Prophylactic treatment
>* ARVs
>
>...
>
>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.
>
>...
>
>*************************************************************
>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.
>
>AfricaFocus Bulletin can be reached at africafocus at igc.org. Please
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>or to suggest material for inclusion. For more information about
>reposted material, please contact directly the original source
>mentioned. For a full archive and other resources, see
>http://www.africafocus.org
>
>************************************************************
>


-- 


Al Kagan
African Studies Bibliographer and Professor of Library Administration
Africana Unit, Room 328
University of Illinois Library
1408 W. Gregory Drive
Urbana, IL 61801, USA

tel. 217-333-6519
fax. 217-333-2214
e-mail. akagan at uiuc.edu