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.

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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.

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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.

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