Tuesday
14th September 2004

11th Septembert 2004
Doctors and nurses with HIV and AIDS in sub-Saharan Africa

8th September 2004
Zambian Government Declares HIV/AIDS National Emergency, Launches Collaborative Treatment Project

13th September 2004
UGANDA'S CRISIS
Generation orphaned by AIDS

24th August 2004
Glaxo to face another hearing on Aids drug prices

10th August 2004
Women Complain of Lack of Access to Aids Drugs.

13th August 2004
3 Generic AIDS Drugs Taken Off WHO Approved List

16 June 2004
U.N. Agency Drops 2 Drugs For AIDS Care Worldwide

16 June 2004
TAC Comment On The New York Times' Article [Above]

1st July 2004
Gilead Science (GILD) Surges As Earnings Trounce Expectations.
Sales Of The HIV Drug Viread Drove The Outperformance, The Company Said.

5th July 2004
ARV Rollout A Shambles, Says Report

12th July 2004
Bangkok Blog

14 July 2004
US Under Fire Over Patent Deals At World Aids Forum

27th July 2004
Copycats' Hit Drugs Firm's Profits

31st July 2004
Thoughts From Bangkok-Part I

1st August 2004
HIV Made Me Feel Ugly And Battered But No More—Rolake Odetoyinbo Nwagwu

9th August 2004
Every Day Is A Fight To Survive For Africans Who Have AIDS

20th August 2004
What The Zambian Government Won’t Say…

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BMJ 2004;329:584-585 (11 September), doi:10.1136/bmj.329.7466.584

Editorial
Doctors and nurses with HIV and AIDS in sub-Saharan Africa

"We're going to run out of people before we run out of money"

Much has been written about the impact of the HIV and AIDS pandemic on the healthcare delivery systems and resources in central and southern Africa. The unremitting pressure on hospitals and other healthcare facilities,1 and the disproportionate use of healthcare resources by the ever increasing numbers of patients, are threatening to undermine the capacity of countries such as South Africa to provide a comprehensive health safety net for the rest of the population.2

An additional threat that has received little or no attention in the literature is the possible impact of illness and death due to the pandemic specifically among healthcare professionals in countries with high HIV prevalence rates. A Medline search on this topic by using a variety of keyword combinations proved unproductive. Therefore the findings a 30% mortality over 20 years largely attributed to HIV infection among a cohort of Ugandan doctors in the article by Dambisya in this issue represent an important contribution in spite of the small numbers and the largely presumptive nature of the evidence (p 600).3

In South Africa, a country that carries 10% of the world's burden of HIV and AIDS while only 1% of the world population lives there,4 the potentially devastating impact of HIV and AIDS among health professionals on the capacity and integrity of the healthcare system is acknowledged, but only preliminary and sketchy data exist in this regard. A shortage of nurses is critical as many emigrate or succumb to AIDS related illness. Nothing is known about HIV and AIDS among doctors.

Olive Shisana and her group at the South African Human Sciences Research Council have conducted the only population based survey to date into the epidemiology of HIV in South Africa, which pegs South Africa's overall HIV prevalence in the general population (defined as those aged 2 years and older) at 11.4% (95% confidence interval 10.0 to 12.7).5 These findings are in accord with the estimates by other researchers derived from computer modelling, from the extrapolation of data from sentinel antenatal surveys, and from the national mortality registry.6 Notably, the prevalence in the study rises to 15.5% (13.5 to 17.5) for the adult population defined as those aged 25 years and older.

In a separate investigation commissioned by the South African health ministry in 2002 looking at the impact of HIV and AIDS on the health sector, the South African Human Sciences Research Council's team found an alarming HIV seroprevalence among professional healthcare workers of 15.7% (12.2 to 19.9).7 Although based on a relatively small sample of 595 subjects, the results show that the prevalence among health professionals is not dissimilar to that of the general adult population. The study does not provide a differential breakdown of the prevalence among the various professionals but notes that "African health workers had a much higher prevalence of HIV than other race groups."

The investigators conclude that "the HIV/AIDS epidemic will have an impact on the health system through loss of staff due to illness, absenteeism, low staff morale, and also through the increased burden of patient load."

The impact is already with us—the nursing profession is the most affected—but secrecy and silence continue to prevent us from getting the facts. A recent report from McCord Hospital, well regarded for its community orientation and as a teaching facility, records how an initiative to reach out and to create a supportive work environment for HIV affected staff following the death of four staff members in four months was met with denial, fear, hopelessness, and an unwillingness to be tested or treated.8 The hospital subsequently succeeded in establishing a trusted and well used diagnostic and treatment programme for its staff.

Three waves have been described in the natural course of the HIV epidemic,9 the depth and duration of which can of course be moderated by the effectiveness (or lack thereof) of interventions for modifying sexual behavioural and antiretroviral treatment: firstly, an expanding incidence of new cases, which in South Africa is deemed to have peaked around 1998; secondly, increasing prevalence thought to be peaking around now; and finally, increasing mortality.

In South Africa, and much of sub-Saharan Africa, mortality is currently spiralling upwards. Ironically, a stronger health system is necessary for more effective prevention and care of HIV and AIDS,10 which the attrition among health professionals will only serve to undermine. Holly Burkhalter, of Physicians for Human Rights, writes in the Washington Post of 12 June 2004 about the brain drain in Africa that "today's biggest limiting factor for AIDS treatment in the developing world is the paucity of trained health workers...We're going to run out of people before we run out of money."11 The same might well be said of AIDS related mortality among health professionals.

Dan J Ncayiyana, vice chancellor

Durban Institute of Technology, PO Box 1334, Durban 4000, South Africa (vice-chancellor@dit.ac.za )

Daily HIV/AIDS Report

Global Challenges | Zambian Government Declares HIV/AIDS National Emergency, Launches Collaborative Treatment Project
[Sep 08, 2004]
The Zambian government on Friday declared its HIV/AIDS epidemic a national emergency, an announcement that will allow for the local production of generic antiretroviral drugs, SAPA/AFP/Mail and Guardian reports. According to Davidson Chilipamushi, permanent secretary of the Ministry of Commerce, Trade and Industry, the state of emergency will last from August 2004 to July 2009, during which time generic antiretrovirals can be produced but not exported. "In view of the pandemic and the high cost of patented antiretroviral drugs ... the minister (of Commerce, Trade and Industry) has signed a statutory instrument (law) to declare an emergency," Chilipamushi said, adding, "Companies, persons who wish to manufacture, use or sell any generic drugs will henceforth require a written authorization ... during the declared period of emergency" (SAPA/AFP/Mail and Guardian, 9/4). Under World Trade Organization agreements, a country must declare a state of emergency before local companies are permitted to produce patented antiretrovirals, according to Xinhua News Agency (Xinhua News Agency, 9/4). One in five adults in the Southern African country are estimated to be HIV-positive, and 12,000 of them receive subsidized antiretrovirals under the government's HIV/AIDS treatment program. Zambia hopes to treat an additional 100,000 patients under the program by the end of next year (SAPA/AFP/Mail and Guardian, 9/4).

Collaborative Treatment Project
Zambian first lady Maureen Mwanawasa on Sept. 1 launched the Muka Buumi antiretroviral therapy clinic, a collaborative treatment project of AIDS Healthcare Foundation Global Immunity, Salvation Army Chikankata Health Services, the Salvation Army World Service Office, the Mazabuka District Health Management Board and the Center for Infectious Disease Research in Zambia. The clinic is located at the Chikankata Hospital in the Mazabuka District and aims to treat and manage 1,000 HIV-positive patients; establish a training center for health professionals to learn about antiretroviral treatment; and implement a program to expand antiretroviral treatment services. "The combination of commitment and expertise in clinical, public health and management skills that are essential for successful HIV treatment programs are brought together by this exciting new partnership," AIDS Healthcare Foundation President Michael Weinstein said, adding, "We look forward to a long and successful partnership in the fight against AIDS in Zambia" (AHF release, 9/3). During the dedication ceremony, Mwanawasa also said that the "exodus" of nursing professionals from the country is affecting the quality of health care services in Zambia, according to the Times of Zambia. Mwanawasa "urged" health care workers to remain in the country and called on the Ministry of Community Development to promote the re-establishment of an extended family system to care for AIDS orphans, the Times reports (Times of Zambia, 9/3).

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Monday, September 13, 2004

UGANDA'S CRISIS
Generation orphaned by AIDS

BY JAMES PALMER
SPECIAL CORRESPONDENT

September 6, 2004

KAMPALA, Uganda - Since his mother died of AIDS in 2002, Julius Kuma, 12, has spent his nights sleeping under a welder's stall made of rusted metal sheeting and scrap wood near a Kampala dump.

He collects scrap metal for money and occasionally rifles through garbage for food, while dodging harassment from the police and other street children.

"Maybe one day I will be blessed and God will give me a good home to stay in," said Julius, whose father died of AIDS about a year before his mother.

According to the United Nations, there are 11 million so-called AIDS orphans across sub-Saharan Africa, children 14 and younger who, like Julius, have lost one or both parents to AIDS. They constitute more than 80 percent of the world's 13.2-million AIDS orphans

Nevertheless, on the continent with the world's worst AIDS problem, Uganda is something of a success. The health ministry says it reduced its HIV-infection rate from nearly 19 percent of the population in 1995 to about 4.1 percent last year, due largely to an aggressive government campaign promoting abstinence or monogamous relationships and condom use, and advertising the dangers of AIDS. In the years before the campaign kicked in, millions of Ugandans became infected and died, leaving up to a million children who, like Julius, have lost one or both of their parents to AIDS.

'They have no one else'

In Uganda, many AIDS orphans live on the streets, dependent on charity and players in a tragedy that caregivers say is destroying the very fabric of Ugandan society: the extended family.

"The family network has broken down because of the AIDS epidemic," said Juliet Tumuheirwe, program director for the Friends of Children Association. The organization depends on donations and provides food, clothing, counseling, job training and English classes to 200 street children in Kampala.

"Children were once absorbed by other family members when the parents died, but now these family members are dying too, so who is left to take care of the children?"

Julius, who doesn't know where his remaining relatives live, gets some help from the Friends association. He is training to be a mechanic, though he has other aspirations.

"I want to find a sponsor who will help me pay school fees, so I can continue my education," said Julius, who earns about 1,000 Ugandan shillings a day, or roughly 50 cents, collecting scrap metal. "I'm too young to be working for a living."

Ugandan women have stepped forward to shoulder the load of caring for orphans, heading 70 percent of orphan households in the country. The majority are widows, often as a result of AIDS.

One of them is Aisha Natale, 40, whose husband died of the disease in 1999. He left her infected with the disease and with their three young children to support. She has taken in an additional four children whose parents died of AIDS.

Natale said she lives on 100,000 shillings per month, or about $50, part of which is donated by Orphans and Widows of AIDS in Uganda, a local aid organization. The rest comes from selling clothes crafted with one of the manual sewing machines that the organization provides.

"I would take in more children if I could," said Natale, who is not certain what will happen to the seven children in her household if she dies before they are independent.

"I care for them and love them for now, because they have no one else."

Community pitches in

Uganda's AIDS epidemic has thrust many of the country's children into the unenviable position of heading the household their parents left behind.

Cotilda Nakusi, 17, inherited the burden of caring for her five younger siblings, who range in age from 3 to 15, after her parents died of AIDS last year. She earns about 3,000 Ugandan shillings ($1.50) a day hand-washing clothes. Neighbors have paid her family's school fees and rent for the cramped room the six siblings share.

Even so, she's worried. "I'm not very confident in this situation," Nakusi said. "The neighbors are helping now, but they may not always be there."

Some AIDS orphans do find homes. The Kamwokya Christian Caring Community places children with no available family members in homes. Doreen Arinaitwe, who was abandoned by remaining family members at 13 after her parents and younger brother died of AIDS, graduated with a degree in education from Kampala's Makerere University after Kamwokya took her in. While Arinaitwe, now 24, lived with one foster mother, the entire neighborhood pitched in to help raise her.

"I wouldn't have achieved what I have if it was not for the community," said Arinaitwe, who teaches history at a primary school in the southwestern town Mbarara.

But many AIDS orphans in Uganda were born with the disease that killed their parents and have limited possibilities. Ugandan health officials say 10 percent of the 1.5 million people living with AIDS in the country are children, and few have the $100 monthly necessary to buy drugs that can delay the onset of the disease.

"In Uganda, if you don't have money, you can't get treatment," said Nantela Prossy, 17, whose parents died of AIDS and who was born with HIV. "I would like to go to America. Many of my friends have gone there to have treatment for HIV."
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