[Peace-discuss] Fwd: Africa: Year of Action for AIDS Treatment?

Sun Jan 9 15:57:55 CST 2005

FYI

Begin forwarded message:

> From: africafocus at igc.org
> Date: January 9, 2005 2:27:06 PM CST
> To: akagan at uiuc.edu
> Subject: Africa: Year of Action for AIDS Treatment?
>
>
> Africa: Year of Action for AIDS Treatment?
>
> AfricaFocus Bulletin
> Jan 9, 2005 (050109)
> (Reposted from sources cited below)
>
> Editor's Note
>
> "The Indian Ocean tsunami killed 150,000, and triggered a
> remarkable global relief effort that has raised $4 billion for the
> stricken region. But AIDS, tuberculosis, and malaria alone kill 40
> times that number every year, taking no fewer than 6 million lives.
> And still, the United Nations must scramble for the $3 billion a
> year it needs to combat these diseases." - Toronto Star, January 8,
> 2005
>
> The torrent of pledges in response to the uniquely visible natural
> disaster in the Indian Ocean is a testimony to human solidarity as
> well as to the power of today's global media. Contributions include
> not only the well-publicized responses from rich countries, but
> also less-noticed contributions from countries and regions
> themselves burdened with pressing humanitarian needs. [For a
> summary of the response from Africa to the Tsunami disaster,
> including $100,000 contributions from Mozambique and from the
> African Union, see the January 5 article from the Afrol independent
> news agency (http://www.afrol.com/articles/15136).]
>
> While the tsunami toll continues to mount, the focus is now less
> on pledges than on ensuring that pledged resources are turned into
> action. And commentators are also beginning to raise other
> fundamental questions. Most significantly, can the response to the
> tsunami be carried over to even more devastating crises that are
> less photogenic, such as AIDS, global health, conflict, and
> poverty? Or will the effect be to reduce resources for implementing
> programs that have not been scaled up for lack of political will
> and resources?
>
> This AfricaFocus Bulletin contains two articles from a year-end
> special by the UN's Plusnews highlighting the current status of
> antiretroviral treatment in Africa, an overview and a report from
> Mozambique. While the scale of the AIDS pandemic differs
> significantly from one African country to another (see
> http://www.africafocus.org/docs04/hiv0412a.php), for the worst
> affected countries the impact of AIDS alone is orders of magnitude
> greater than the toll inflicted by the tsunami on all the countries
> involved.
>
> Despite significant expansion of programs in the last two years,
> only four percent of the estimated 3.8 million people in need of
> such treatment in Africa now have access. Global spending on
> HIV/AIDS in low and middle-income countries was estimated at $6.1
> billion in 2004, with the need projected at $12 billion for 2005.
>
> The year began with Nelson Mandela's courageous statement
> acknowledging that the death of his son was due to AIDS, and
> calling on others to speak out as an indispensable step to
> countering the disease. The articles below indicate that while the
> obstacles of political will and resources are still formidable, the
> basic outlines of what needs to be done are in place.
>
> ++++++++++++++++++++++end editor's note+++++++++++++++++++++++
>
> Africa: the Aids Treatment Era - Introduction
>
> UN Integrated Regional Information Networks
> http://www.irinnews.org
>
> December 31, 2004
>
> Johannesburg
>
> [Excerpts. For full text and additional articles, see the PlusNews
> Special at http://www.plusnews.org/webspecials/ARV/default.asp]
>
> 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 antiretroviral treatment (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. [For this and other Equinet reports, see
> http://www.equinetafrica.org]
>
> 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. ...
>
> Build it and They Will Come?
>
> But where ART is available, stigma, seemingly inexplicably, still
> influences people's response to treatment. ...
>
> 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. ...
>
> 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 (http://www.nu.ac.za/heard/free/freeby5.asp)
> 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. ...
>
> "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.
>
> *************************************************************
>
> Overview - Focus on Mozambique
>
> Mozambique is a catalogue of the problems that poor countries face
> when they expand antiretroviral therapy (ART).
>
> National HIV prevalence in 2004 is projected to be 14.9 percent
> among people aged 15 to 49, based on sentinel surveillance by the
> ministry of health and the National Institute for Statistics. The
> average hides sharp disparities between provinces, ranging from
> 26.5 percent in Sofala to 8 percent in Nampula. Provinces bordering
> South Africa, Zimbabwe and Malawi are the worst affected.
>
> Among the estimated 1.4 million people infected, 218,000 need
> treatment in 2004, according a National Institute of Statistics
> study.
>
> As of November 2004, 5,900 people were on ART: 4,200 through NGOs,
> 1,200 at Maputo Central Hospital, a few hundred at provincial
> sites, and about 50 through private health care.
>
> The goal was to have just under 8,000 people on ART by the end of
> 2004, with an annual increase to 20,800, 58,000, and 96,000 -
> reaching 132,000 in 2008.
>
> Healthcare Providers
>
> The first problem is lack of human resources. There are 800
> doctors, 300 of them expatriates, in a population of 18.9 million.
> This means one doctor for every 24,000 people, against one per
> 5,000 to 10,000 recommended by the World Health Organisation. The
> 11,000 nurses represent one per 1,700 people, while WHO recommends
> one every 300.
>
> Healthcare is also unevenly spread: 80 percent of doctors are in
> Maputo, the capital; among all health staff, those in the provinces
> have the lowest qualifications.
>
> Due to AIDS-related deaths, Mozambique needs to train 25 percent
> more doctors and nurses every year just to maintain the existing
> low levels of staffing, says a study by the ministry of health.
>
> The University Eduardo Mondlane, the new National Health Institute
> in Maputo, and the new Nursing School in Beira are increasing
> student uptake, but to retain them in the country after graduation
> will require better salaries and working conditions.
>
> Meanwhile, with donor money to offer monthly salaries of US $3,000,
> the government is recruiting 120 doctors in Cuba and India.
>
> Infrastructure
>
> Another problem is poor health infrastructure. In the provinces,
> sub-standard facilities and lack of basic equipment is common. Many
> of the 27 rural general hospitals operate below minimum acceptable
> standards, says the Health Sector Strategic Plan 2002-2005.
>
> To enable ART, the Italian Catholic NGO, Communita de Santo Egidio,
> rehabilitated three molecular laboratories with state-of-the art
> equipment. The biggest, at Maputo's Central Hospital, cost US
> $450,000; those in Maputo and Beira are operational, and Nampula
> will open soon to serve the northern region.
>
> In the meantime, blood samples are sent weekly from the north to
> Maputo by courier airplane - run-down inter-provincial roads make
> some airfreight unavoidable.
>
> The lab in Maputo offers training for health personnel from
> Mozambique and other African countries where Santo Egidio plans to
> start ART.
>
> At Maputo Central Hospital, Brazilian cooperation funds ARV
> training for doctors and nurses, and to date 200 doctors have been
> trained, so that every province now has ARV-competent doctors.
>
> Dr Rui Bastos is the Mozambican training coordinator. "We are
> overworked," he says. "We lack diagnosis capacity, drugs for
> opportunistic infections, nurses, psychologists and resources in
> general." ...
>
> Treatment Providers
>
> Two NGOs, Medecins Sans Frontieres (MSF) and Santo Egidio, run
> model community-based care and treatment projects: MSF treats 1,700
> patients in Maputo and Lichinga; Santo Egidio runs 13 sites in
> Maputo and Beira, treating 2,500 patients.
>
> By 2007 Santo Egidio plans to treat 8,400 persons at 20 sites in
> five provinces.
>
> In Maputo, MSF is working at full capacity. Its clinic there has
> 1,500 patients on ART and a waiting list of 1,000. "It is
> frustrating, but our human and financial resources are limited,"
> says MSF general coordinator Patrick Wieland.
>
> MSF employs 20 medical staff in Maputo, including two Mozambican
> and three foreign doctors, and 10 non-medical staff. The total
> annual cost of the programme is $2.5 million, but, being
> donor-dependent, MSF can only guarantee five years of treatment,
> and continuation hinges on additional funding. Patients must
> understand this, sign consent forms, and hope.
>
> "It is not our role to treat everyone," says Wieland. "We showed
> ART is feasible; we can train others, but we cannot substitute for
> the government."
>
> Santo Egidio operates on a different model, at a lower annual cost
> of $2.2 million. The Catholic charity relies on volunteers from
> Italy and other countries, who pay their travel to Mozambique
> during holidays and work one month for free at its sites.
>
> The annual treatment cost per patient at Santo Egidio is $700,
> broken down to $300 for generic antiretrovirals (ARVs) and $400 for
> tests and other support.
>
> The success of such ART programmes in Mozambique and elsewhere in
> Africa lies in strong community involvement regarding patient
> identification, selection, care, support and monitoring. It is
> labour and capital intensive.
>
> Besides drugs and tests, patients need good food, clean water and
> a healthy environment; mothers need formula for babies. Santo
> Egidio distributes food, insecticide-treated mosquito nets, water
> filters and home-based care kits, while MSF has partners who
> provide this support.
>
> Can these schemes be replicated by the public health sector?
>
> "As it is, no," says Wieland. "Local solutions are needed - there
> is no other choice."
>
> Gabriella Bortolot, coordinator at Santo Egidio, says: "We can't
> export a western model to Africa, but the challenge is to develop
> an African model of quality care."
>
> Local solutions include using non-medical personnel at all levels.
> Lay community workers, trained and supported by referral systems,
> can run pharmacies, do routine follow-up, counselling, and home or
> palliative care; nurses and clinical officers can offer
> prescription and consultation, while community health workers can
> monitor patients for toxicity and clinical failure, freeing scarce
> doctors to attend mainly to complications.
>
> Eliminating the requirement for viral load and CD4 counts before
> starting treatment bypasses expensive tests.
>
> Expansion
>
> Mozambique began planning nationwide ART in 2002 with a degree of
> reluctance: health authorities knew first-hand the problems
> involved. "AIDS should not detract from other health services, it
> should reinforce them," says Dr Mouzinho Saidi of the National
> Programme to Fight HIV/AIDS.
>
> The examples of successful ART schemes run by NGOs helped dissolve
> the initial reluctance, but today the government is under pressure
> from activists and donors alike to expand treatment access.
>
> "We are resisting donor pressure to increase the numbers because we
> want to grow in a sustainable way," says Saidi. "If we lose
> control, drugs will end up [being] sold on the streets and patients
> will not be properly monitored." The fear of creating resistant
> strains of the virus is palpable, as is the fear of donor funds
> shrinking in the future. ...
>
> The ethical imperative and the practical feasibility of ART in
> Africa are now widely accepted. The challenge is at what pace and
> how.
>
> "Scaling-up was decided by donors in foreign capitals, who don't
> know the on-the-ground reality of treating patients," says Wieland.
> "Westerners like to do a lot quickly, and have quick impact, but we
> need long-term strategies to sustain results, not relying on donors
> and their whims."
>
> Coordination
>
> Throughout the interview with PlusNews, Saidi stressed one point:
> coordination. "We can't have disorganised growth or parallel
> systems for treatment, drug procurement and drug supply," he
> explained.
>
> Mozambique, like other developing countries, has a variety of
> health care providers, including the state, NGOs, churches and the
> private sector. ART began in Mozambique with NGOs; the public
> health sector came later. The challenge is to coordinate the whole
> spectrum of ART providers. ...
>
> Donor Dependency
>
> In UNDP's Human Development Index, Mozambique ranks at 171 out of
> 177 countries. In 2003 its GNI per capita was US $210, compared to
> an average of $450 in sub-Saharan Africa.
>
> In 2000 foreign aid accounted for 70 percent of all spending on
> health, 46 percent of education expenditure and 75 percent of the
> funds spent on infrastructure, such as roads and water.
>
> In 1999 foreign aid provided 52 percent of the $100 million health
> budget, notes the Health Sector Strategic Plan. With increased
> foreign funding for AIDS, the ratio is higher today.
>
> Mozambique is one of the most donor-dependent countries in the
> world, and its treatment plan echoes this. The government worries
> about the long-term sustainability of treatment, and the recent
> wrangle among donors about next year's financial support for the
> Global Fund to Fight AIDS, TB and Malaria feeds these concerns.
>
> Then you meet Ana Maria Muhai, 43, a dynamic activist in Machava on
> the outskirts of Maputo. Her miner husband returned from South
> Africa in 1998 with a retrenchment bonus and promptly left her and
> their three young children when she became sick.
>
> In February 2002, Muhai, weighing 29 kg, ravaged by opportunistic
> infections, bald, with horrible skin rashes and a bad cough,
> arrived at the clinic. In three weeks ARVs brought her back from
> the brink of death.
>
> Today, a healthy Muhai helps patients with treatment adherence.
> When some ask if she is paid by the Italians to say she is HIV
> positive, she pulls out an old photo. "Then they see it is for real
> - I know it is not a cure, but I feel cured," she says.
>
> There are 1.4 million people like Ana Maria Muhai in Mozambique,
> whose contribution to family, community and nation is unique,
> irreplaceable, and threatened by the virus.
>
> *************************************************************
> 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
Africana Unit, Room 328
University of Illinois Library
1408 W. Gregory Drive
Urbana, IL 61820
USA

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