The editorials in this newsletter comment on two global events, two months apart. The first is the 18th International AIDS Conference held in Vienna in July, and the second the UN Summit on the Millennium Development Goals being held in New York in September. Both conferences have triggered a wealth of ideas, debates and publication, some of which we include in the newsletter. Both deal with heads of state commitments, made in prior conferences: The first to universal access to treatment for AIDS, the second to the eight MDGs. In the first editorial Sharonann Lynch reminds that after the “talk and spectacle”, many conference participants go back to work in impoverished realities. She suggests concrete people-centred strategies for delivering on treatment commitments in these conditions. In the second, Ranga Machemedze asserts that many living in the most impoverished realities have not yet benefited from the MDGs, even when progress has been made at national level, and asks what the UN Summit will do to close the gap. For both, the test of the global talk is the concrete local improvement it produces for the most disadvantaged communities.
Editorial
After the 18th International AIDS Conference (IAC) has wound down in Vienna, the word in the hallways is that the science is in: earlier initiation of treatment and improved antiretroviral (ARV) drug regimens are better for individual patients and communities, and may even ultimately reduce transmission of HIV. Some of the new data presented at the conference come from MSF's project in Lesotho, where I worked from 2006 to 2009. In a two-year study of 1,128 patients from rural Lesotho, where the government has adopted new World Health Organization (WHO) guidelines, patients starting treatment earlier (at CD4 count <350) were 70% less likely to die, 40% more likely to remain in care, and >60% less likely to be hospitalized compared with those started when their disease was already advanced (CD4 <200).
After all the talk and spectacle, many of us—people with HIV/AIDS, clinicians, researchers, and activists—will have to go back to reality: to townships and rural villages still ravaged by the virus; to congested clinics with waiting lists for treatment; and to rich country capitals where donors are ignoring the science and retreating from their commitment to fully fund universal access to treatment, telling us to get used to this new reality—we are in the midst of global economic recession, after all.
At the conference there was a lot of talk about cost-effectiveness and efficiency as a means to mitigate funding shortfalls. Sure, we need to avoid waste and the obscene number of consultants and reports that sit on shelves in Washington, Geneva, and London. But how do the actual people fit in to these crude calculations? What is the cost-benefit to their lives, families, and communities?
We are advocating for a different vision: for patient-centered efficiencies that will increase access to treatment and reduce the burden on patients in taking toxic drugs, reporting excessively to health facilities, and traveling great distances to seek care. We also want efficiencies to reduce the requirements on the health system, for example through task-shifting and community-based, out-of-facility approaches to drug dispending and social support. And economists are telling us these sorts of efficiencies will even be cost-saving in the long run.
So how do we build on Lesotho's example and get more patients on treatment? Here are some forward-looking ideas that could change the game:
* Invest in rigorous research and pilot projects to explore the feasibility and impact of "treatment as prevention." Treatment is increasingly understood to have major prevention benefits, in addition to reducing HIV- and TB-related illness and death.
Support research to radically simplify and optimize the package of ARV treatment, including:
* Dose optimization: If shown to be effective, reducing the dose of some ARVs could potentially treat up to one-third more patients without a cost difference.
* New drug development: Develop new ARV drug delivery platforms and slower-releasing drugs, which could help to decrease the burden on patients as well as the cost per patient per year.
* Accelerate commercialization of point-of-care diagnostics: new instrument-free, point-of-care CD4 cell count blood tests, once available, could be rapidly deployed to the field for use in identifying more patients at the lowest levels of care, while we redouble efforts to develop a point-of-care viral load test.
And additionally;
* Create and implement a financial transaction tax (FTT): billed by some as the "Robin Hood tax" (including activists at IAC dressed up in feathered green hats and bows and arrows), a tiny tax of 0.005% on foreign currency transactions could generate an estimated $33 billion per year for global health needs and other issues affecting the developing world. Such a "tax and treat" strategy could deliver the sufficient, regular, and predictable funding to pay for scale-up, provided donors make good on their existing commitments to the Global Fund and other financing mechanisms.
* Ensure an enabling policy environment to usher in these new innovations, including aggressive use of Trade-Related Aspects of Intellectual Property (TRIPS) flexibilities and an effective patent pool.
If we want to bend the curves of the HIV epidemic, we should seriously consider and put into action radical game-changers such as these.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This article is Open Access and was reprinted freely under a Creative Commons license. http://speakingofmedicine.plos.org/2010/07/23/msf-beyond-vienna-possible-game-changers-for-scaling-up-optimal-aids-treatment. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org or see MSF's website at http://aids2010.msf.org.
According to UN reports, sub-Saharan Africa has the world’s highest rate of child mortality, with one in seven children dying before their fifth birthday. The region has witnessed a 22% decline in the under-5 mortality rate since 1990, although significant variation exists between countries. Although rates of infant mortality have declined since 1990, 17 of the 20 countries with the highest infant mortality rates are African. Maternal mortality is the health indicator that shows the widest gaps between rich and poor, both between and within countries. While data is scarce, WHO estimates that 900 women die per 100 000 live births in Africa. The continent, with the exception of Namibia, is identified by the UN as experiencing high or very high maternal mortality. Sub-Saharan Africa is also the region most affected by the HIV/AIDS epidemic, with over two thirds of all people living with HIV worldwide, and nearly three-quarters of AIDS-related deaths. There are some positive signs: the rate of new HIV infections has slowly declined, and 44% of adults and children in need of antiretroviral therapy had access to treatment, up from 2 % five years earlier. Efforts to combat malaria have progressed: the use of insecticide treated nets by children in 26 African countries rose from 2% in 2000 to 22% in 2008.
African countries have developed numerous strategies to reach the goals. In 2006, the African Union endorsed the Maputo Plan of Action on Sexual and Reproductive Health and Rights, and 22 countries have since set Maternal and Newborn Health Road Maps to improve sexual and reproductive health through laws, policies and health systems. The AU’s African Health Strategy 2007-2015 proposes to strengthen equitable health systems; the AU’s 2005 Gaborone Declaration commits to universal access to HIV prevention, treatment and care; the 2001 Abuja Declaration commits African states to allocate 15% of their national budgets to health and the 2008 Ouagadougou Declaration commits to advancing Primary Health Care and Health Systems in Africa. The 2010 African Union summit held in July in Kampala, passed a number of resolutions, including a renewed commitment to the 15% budgetary allocation to health; and CARMMA- the Campaign for the Accelerated Reduction of Maternal Mortality in Africa.
The African Union and its member states must, however, go beyond rhetoric to implement the promises set out in their declarations and produce tangible results. For example, the Global Fund has reported that as of 2007, out of 52 African countries (no data was available for Somalia), only three (Botswana, Djibouti, and Rwanda) had met the 15% target for health budgets, while three more (Liberia, Malawi and Burkina Faso) surpassed this target.
The UN report, Keeping the Promise – United to Achieve the Millennium Development Goals for the 2010 MDG summit being held in late September in New York has a paragraph on Africa stating that the continent is lagging behind on many of the MDGs, that progress has been made in some African countries but that the poorest ones remain “a grave concern, especially in the wake of the hard hitting financial and economic crisis”. The UN note in the report that while aid to Africa has increased in recent years, it still lags far behind commitments made. Will the Summit produce the resources called for by the UN through delivery of these commitments? Will the UN MDG Summit in September go beyond rhetoric to action? Will it unleash the resources to move from the many strategies to practice?
After all is said and done in September, one sign of that must be the extent to which whatever is said is translated into local level interventions and reaches vulnerable groups. This needs to be tracked, but the UN only collects MDG data aggregated at the national level, making it difficult to track how far this is being achieved. There is no provision in country reports for disaggregation of country-level data to assess sub-national progress on the MDGs. The reports do not therefore capture the stark inequalities among different regions, socio-economic, ethnic, racial and cultural groups within countries on accessing the resources for health or achieving the MDGs.
And should we be measuring targets or rates of progress? The World Bank noted in 2010 that uniform goals like reducing infant mortality by two-thirds, maternal mortality by three-quarters can underestimate progress in poor countries and communities. Why? Because the greater the distance to the goals from low starting points in poor countries, the greater the improvement needed to reach the targets. Is it the rate of progress, or the likelihood of achieving the targets that should be evaluated? While the target is the outcome we are aiming for, Fukuda and Greenstein argued in 2010 that the rate of progress tells more about the likelihood of achieving it along the way, and would place more pressure on governments to do more.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. This editorial has been edited from the original that appeared in the Health Diplomacy Monitor Special Issue on the UN Summit on the Millennium Development Goals, Vol 1 Issue 3. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org or see the Global Health Diplomacy website at www.ghd-net.org.
In this issue we bring news of cause to celebrate, but also a call for action on an expanding IP enforcement agenda that challenges our rights to health. In the section on 'Resource allocation and health financing' we welcome the heads of state restatement of their 2001 Abuja commitment to allocate at least 15% of annual budgets to health. EQUINET was part of this campaign (have a look at Newsletter #113) and while we recognise that 15% of government's own spending may not be sufficient resources for health, it does signal a prioritisation of the domestic and public sector role in health. This newsletter editorial draws our attention to an issue that needs attention, and more than that, action. In the competition between social rights to health, and private rights to intellectual property, our dependence on medicines purchased from outside Africa makes us weak defenders of rights to health.
The 18 to 23 July International AIDS Conference held in Vienna this year, subtitled “Rights Here, Right Now” was a platform to raise, yet again, the values based universal and indivisible human rights and the political commitments that inform our response, globally, to the unacceptable level of new HIV infection and mortality from AIDS. At the same time the shrinking provision of aid to low income countries and persistence of avoidable inequities globally in the progressive realisation of these rights starkly raises the reality of the competition between social rights to health, and private rights to intellectual property.
International aid to developing countries has declined in the past two years, with a fall of $1.1 billion in high income country support for developing country AIDS programmes between 2008 and 2009, according to UNAIDS and Kaiser Foundation. At the same time rich countries continue to pursue with vigour stronger protections for intellectual property rights (IPR) – in what is now known as the ‘IP Enforcement Agenda”. The effects of strong IPR protection may have been abated in earlier years by aid support for purchase of patented medicines, but low income countries seeking to meet needs in the current financial squeeze by procuring cheaper options or initiating their own local production of medicines, including of anti-retrovirals, face an unabated challenge to their implementing even those measures that are legal under the World Trade Organisation's (WTO's) Trade-Related Intellectual Property Rights (TRIPs) agreement.
The fall in funding to AIDS has itself been challenged by many, including the President of the International AIDS Society, Dr. Julio Montaner, and Stephen Lewis (former UN special envoy for HIV/Aids in Africa). As Dr Montaner said: “International governments say we face a crisis of resources, but that is simply not true: The challenge is not finding money, but changing priorities. When there is a Wall Street emergency or an energy crisis, billions upon billions of dollars are quickly mobilized. People’s health deserves a similar financial response and much higher priority.”
At the same time the fall in funding has made very clear the need to implement long-standing calls by progressive civil society to put in place more predictable means of global financing, and for African countries to maximise use of TRIPS flexibilities and to advance local production of pharmaceuticals. Yet is it precisely in this arena that measures are being taken to strengthen and enforce intellectual property rights and reduce the flexibilities needed by developing countries. There have been numerous examples of this, included those reported in prior issues of the EQUINET newsletter.
Measures to reinforce IPRs include in regional and bilateral agreements provisions that exceed TRIPs requirements and reduce the flexibilities provided by TRIPS (TRIPS plus); and also pressures on African countries not to exercise rights to compulsory licensing or parallel importation. The EU, which stated its commitment to access to medicines, has pursued measures that exceed TRIPs obligations in its trade agreements with developing countries including with India, in spite of an EU Parliamentary resolution on 12 July 2007 (P6_TA(2007)0353) urging it not to do so. There have been seizures in the EU of generic medicines in transit, not destined for Europe, performed at the insistence of EU pharmaceutical companies for allegedly being counterfeit. The EU has contributed to work on anti-counterfeiting legislation in East African countries that has raised new IPR restrictions on legitimate generic medicines, defining them within the scope of counterfeits (see EQUINET Newsletter 111). Similar seizure laws are being supported through a global initiative called IMPACT.
Significantly at the July AIDS conference, attention was also drawn to the use by the USA of its ‘Special 301’ law which it uses to list and “shame” countries for violating US commercial interests by not providing sufficient protection to IPRs. Health Gap, the Foundation for AIDS Rights and the Thai Network of People Living with HIV/AIDS with others have filed a complaint with the UN's Special Rapporteur on the Right to Health, Anand Grover, alleging that use of this law reduces access to medicines in low and middle income nations and violates international human rights obligations.
Global institutions appear to be offering weak protection to developing countries in their efforts to assert their rights, and the rights and flexibilities provided for in global treaties. In the 2006/7, during the WHO's negotiations on Public Health, Innovation and Intellectual Property (for so-called “neglected diseases”) efforts were made to contain the challenge to IPRs from neglected diseases by including a proposal to limit the scope of the discussion to only 14 diseases, a due process violation as no country proposed this for inclusion in the negotiating text. The IMPACT programme referred to earlier has had an association with WHO that was heavily criticised at the 2010 World Health Assembly. The WTO Dispute Settlement Body (DSB), instead of the defending the flexibilities provided in its own instruments through multilateral measures, has allowed the US room for unilateralism on its Special 301 law in a January 1999 dispute raised by the European Community. This was a decision that Chakravarthi Raghavan of the South-North Development Monitor termed as blatantly based on politics, rather than legal interpretation.
Almost a decade since the 2001 Doha Declaration on TRIPS and Public Health made the important step of asserting more clearly the rights countries already enjoyed to promote access to medicines, few countries have been able to use the rights enshrined in it. The Declaration was needed then because poor countries were precluded from using these rights by the rich countries. The cases cited in this editorial suggest that the last decade has been one of countless efforts to restrict and reverse those rights.
This is in a context where the latest WHO treatment guidelines recommend that people with HIV should start treatment earlier, bringing treatment for people in developing countries in line with treatment in wealthy nations, to help prevent transmission of HIV. Of the 14 million people needing treatment, only 4 million currently receive it. While private rights to IPRs are being vigorously enforced, who is vigorously enforcing the rights to life and health of these 10 million people, or the millions more who need medicines for other common diseases, including chronic conditions like diabetes and hypertension?
And where will we be ten years from now, with an unabated and expanding IP enforcement agenda?. The evidence from recent years outlined here suggests that basing future access to medicines on a benevolent global market, or even one that prioritises human rights in one region over commercial rights in another may be wishful thinking. There seems to be no alternative but for African countries to set a vision, and to develop, negotiate, build space for and implement strategies for their own local production of medicines, to meet their own market and population needs, while simultaneously fending off an IP enforcement agenda that does not meet their interests, in all its guises.
A quarter of the population in Sub-Saharan Africa are young people between the ages of 10 and 19 years. These young people carry the hopes and dreams of their families, their communities and their nation. They are the future leaders and, perhaps as important, the future parents of the next generation.
They live in a world where to be an adolescent is increasingly risky. Adolescents typically take risks, but with the AIDS epidemic, risk-taking can be fatal. When adolescents have unplanned and unprotected sex, sexually transmitted infections can cause infertility or cervical cancer, and pregnancy in adolescents is more risky, with higher rates of death in both adolescent mothers and their babies than in adults. Unsafe abortions amongst adolescents are unacceptably high, and early sexual activity may limit educational attainment and deprive young people of the opportunity to form mature, loving relationships. So it’s a tragic and unacceptable sign that most new HIV infections in sub-Saharan Africa occur among adolescents and young adults.
Adolescents grow up today in a different world. High rates of urbanization, extended periods of schooling and growing poverty contribute to a challenging social context for young people.
Traditional ways of preparing young people for adulthood, which relied on extended family members, are less practiced and might not be adequate to address the pressures that adolescents face. In the past, sexual maturity was closely followed by marriage. Today, young people reach puberty at younger ages and wait longer to marry. Because the aunt or uncle may not be available, or may not be considered relevant, many adolescents turn to other sources. Today, many young people learn from peers or the media. Much of this information is inadequate and sometimes it is just plain wrong.
Schools are an ideal setting in which to reach large numbers of young people with the information they need, including reproductive knowledge and life skills. Yet, wherever it has been introduced, the teaching of reproductive health in schools has generated controversy. Debate exists around what information should be given and how much, especially regarding sexual intercourse, pregnancy and disease prevention. Some adults are resistant to even acknowledging that teenage sex is taking place. Others are concerned that sex education will lead to sexual activity. These viewpoints are often based more on values and beliefs than on facts. Hence the same arguments are repeated again and again, year after year, despite contrary evidence. Its very likely these same views will continue to be expressed into the future.
Nevertheless, facts do help. Studies have shown, both regionally and internationally, that comprehensive sex education is effective in improving knowledge and reducing sexual risk behaviours, and that it does not increase sexual activity. In 1997, a UNAIDS study reviewing 53 sex education programmes globally found that 22 had a positive effect of safer adolescent sexual behaviour, and 27 had no impact. In the 3 studies where there was an increase in sexual activity, there were concerns about the design of the assessment and the validity of conclusions.
Such studies suggest that rather than sex education causing young people to have sex, the opposite is more likely to be the case: Giving young people more complete and accurate information, and more opportunities to discuss issues in an open and non-judgemental environment enables them to make more responsible choices.
Clearly the design and quality of the programme matters. Strengthening sex education programmes can be difficult in resource-strained countries. However some aspects of effective programmes that have been identified from reviews can be applied across different settings, including those where resources are scarce. These include:
• adopting school curricula that provide comprehensive, accurate sexual and reproductive health information;
• supporting teacher training;
• reaching young adolescents with information early, before they leave school and before they begin sexual activity;
• strengthening health and other community services for young people and ensuring that these services are youth-friendly, and
• helping adolescents stay in school. Even if they do not receive sex education, young people who stay in school are less likely then their peers to have sex.
Successful reproductive health programmes are not simply a matter of education. They involve youth issues, gender issues, human rights issues, and health issues. They involve and give a central role to youth themselves. They encourage young people to articulate and discuss issues, to talk about their lives, to understand their options, and to get the skills and support they need for healthy choices. And of course, for young people, they must also be fun.
Our efforts towards reducing maternal mortality or new HIV infection cannot be said to be successful as long as we have not made significantly more progress in reducing the risk for adolescents. Achieving this and reaching young people can’t be left to teachers alone. Parents, civic leaders, health providers, other government ministries all have a role to play. Support of youth is a multi-sectoral effort. As adults planning for a better future for our young people, we are all their parents.
Please send feedback or queries on the issues raised in this briefing to the EQUINET secretariat: admin@equinetafrica.org. For more information on the issues raised in this op-ed please visit the EQUINET website at www.equinetafrica.org or see as an example of resources for adolescent reproductive health the Auntie Stella materials on the TARSC website at http://www.auntiestella.org/
With the World Cup football taking place in South Africa absorbing attention, its possible to miss two important meetings taking place at the same time. The first is the 36th G8 and G20 summits taking place in Canada in late June under the theme 'Recovery and New Beginning', and the second the 15th African Union Summit on 19–27 July in Kampala, Uganda, under the theme ‘Maternal, infant and child health and development in Africa’. This newsletter flags concern over these leaders keeping the promise: G8 leaders to their development and aid commitments and African leaders to the Abuja commitments on health, including for 15% of their budgets to go to health. In this issue, a 63rd World Health Assembly resolution points to the need for strengthened health systems to address the relatively slow progress in Africa towards the health MDGs. Geoffrey Njora cautions leaders on taking the advice of finance ministers’ to reverse on the commitments they made at Abuja. Médecins Sans Frontières call the G8 to account over the 'flatlining' of AIDS funding and Oxfam over the inadequate resources allocated for maternal health. African civil society through the Africa Public Health Alliance & 15% Plus Campaign are petitioning AU Heads of States on the grave concerns of African citizens to meet crucial commitments on health and social development in Kampala, in particular the 2001 Abuja pledge on health financing, while the Civil Society Forum on the African Charter on the Rights and Welfare of the Child call for the G8 and African leaders to meet their promises on funding health as we get closer to 2015. What governments deliver at these two summits is worth keeping an eye on- it affects millions of lives.
African civil society through the Africa Public Health Alliance & 15% Plus Campaign are petitioning AU Heads of States through Malawi President Bingu wa Mutharika, Chairperson of the African Union on the grave concerns of African citizens that some Heads of State are being advised to repudiate crucial commitments on health and social development, in particular the 2001 Abuja pledge on health financing. They note that despite some recent progress, healthy life expectancy in Africa is at a low of 45 years resulting in un-fulfilled personal, national and continental potential and aspirations, and the loss of billions of dollars in productivity. They note that it would be a historic setback for African governments to drop health and social development commitments, or suggest in anyway that the health of African economies exists in isolation from the overall health of African citizens. Giving evidence to support the need for adequate health sector financing, the petition urges heads of state to ensure that the July 2010 AU Summit restates the Abuja commitments; and supports the AU Commission in working with governments and civil society to monitor and report on health gains, and ensure a 10th year review of the 2001 Abuja commitments by April 2011.
The author flags concern about the actions of some African finance ministers to reverse their Heads of state commitments, such as those made on 15% government funding to health in Abuja in 2001. South African, Rwandan and Egyptian finance ministers succeeded in deleting any reference to budgetary targets for education, health, agriculture and water from the report and resolutions of the annual meeting of the African Union and Economic Commission for the Africa Conference of Ministers of Finance, Planning and Economic Development held in Malawi in March 2010. Many consequences are seen to flow from this, if heads of state follow the same path. It could indicate an abandonment of the bold financing that has gone into reversing vulnerability to food insecurity, disease and denial of access to health care and education. It questions how Africa would, after reversing from its own commitments, hold the G8 and international community to their commitments to contribute 0.7% of their gross national product and to double development assistance to Africa. The dismissive nature with which the finance ministers have treated these targets begs the question of whether the MDGs and all the other decisions taken under the auspices of the African Union will go the same way.
The Civil Society Forum on the African Charter on the Rights and Welfare of the Child (ACRWC) has written this open letter to G8 Countries to urge them to meet their promises for external funding to African countries, noting that countries have failed to fulfil their promise for increased aid allocation to Africa – with assistance from France and Germany increasing by just 25%, while Italy is actually set to reduce its contribution by 6% this year. They also urge for continued commitment within Africa to pledges made by leaders. The members note that while domestic allocations are difficult to achieve with all the pressures on very limited resources, they are critical for the health sector if we are to meet the MDGs. The letter draws special attention to the need for investing in maternal, newborn and child health. ACRWC is urging African leaders to endorse the letter. They ask readers to circulate the letter through networks and for those connected, directly to the Africa leaders.