There is no question that an effective and urgent response is needed to extend access to antiretroviral therapy (ART) in southern Africa. The efforts of treatment activists, national governments, the World Health Organisation and the Global Fund to highlight this unmet health need are commendable. However, after decades of under-investment, harmful structural adjustment programmes and de-skilling, many health systems face significant obstacles in rising to the challenge of meeting the treatment needs. Treatment activism now needs to join with broader public health activism to ensure that treatment can be extended in ways that are sustainable, effective and equitable. This paper draws on work carried out by EQUINET and others to discuss the threats and opportunities entailed with the expansion of ART access in Southern Africa- threats that must be managed and opportunities tapped to realise aspirations of treatment access for more than a minority.
Equity and HIV/AIDS
Interventions focusing on HIV-infected pregnant women need to be complemented by interventions that address primary prevention of HIV infection, particularly in women of child-bearing age and their partners, and prevention of unintended pregnancies among HIV-infected women. This is one of the findings of a paper that analyses the different alternatives that are available for the prevention of mother-to-child transmission (MTCT) of HIV in resource-constrained settings, and makes recommendations about the best course of action in a number of situations.
The meeting was focused on ensuring universal treatment access through sustainable public health systems. The goal of the meeting was to develop resolutions on the principles for strengthening health systems for treatment access, and to develop potential areas for work for EQUINET related to EQUINET’s programme of work areas. In the introductory remarks, it was indicated that while there were various prevention activities, focused on for example, workplace education, condom promotion, sexually transmitted infection treatment and control, youth, women, commercial sex workers, men who have sex with men, etc, there was 2.2 million Tanzanians living with HIV out of which 800 000 have full-blown AIDS.
About 90 non-governmental organisations (NGOs) in South Africa's KwaZulu-Natal province have teamed up to work with the government in rolling out antiretroviral (ARV) drugs, in the first structured civil society response of its kind in South Africa, and possibly even on the continent. When the government announced a national rollout plan for free ARVs in September 2003, Cati Vawda, director of the Durban-based Children's Rights Centre, and a number of her NGO colleagues, quickly realised that "government alone cannot do it".
This summary document presents: The principles for ensuring universal treatment access through sustainable public health systems; The major findings and issues from the work carried out in southern Africa on equity in health sector responses to HIV and AIDS, particularly in terms of access to antiretroviral treatment; The key challenges for follow up work identified at the southern African regional meeting on 'Strengthening Health systems for treatment access and equitable responses to HIV/AIDS' in Harare, Zimbabwe, February 2004.
The experience of tuberculosis treatment in Africa shows that the potential short term gains from reducing individual morbidity and mortality may be far outweighed by the potential for the long term spread of drug resistance, says an article in the British Medical Journal. Given the high levels of HIV prevalence and the lack of resources and infrastructures, HIV/AIDS antiretroviral therapy is likely to be introduced to Africa in a random and haphazard way, with inconsistent prescribing practices and poor monitoring of therapy and adherence: this risks the rapid development and transmission of drug resistance.
International health charities have accused George Bush's administration of trying to block developing countries' access to cheap AIDS drugs by questioning the quality of "three in one" generic combination drugs. At a meeting last month in Gaborone, Botswana, the US global AIDS coordinator, Randall Tobias, said that the World Health Organisation's drug pre-qualification programme is not a sufficiently stringent approval process to ensure consistency and quality of fixed dose combination drugs. Médecins Sans Frontières and other non-governmental organisations working with AIDS patients in Africa accused the US government of trying to escape the 2001 Doha agreement on affordable drugs by the side door.
Less than 10% of HIV-positive individuals in South Africa will be eligible to receive antiretroviral therapy if World Health Organisation guidelines which mandate the use of anti-HIV therapy in patients with a CD4 cell count below 200 cells/mm3 are followed, according to a French-funded study published in the May 1st edition of the Journal of Acquired Immune Deficiency Syndromes. The study also found that this would have only a limited impact on the spread of HIV.
Stigma and discrimination are still huge obstacles to progress on AIDS: the association of HIV/AIDS with marginalised populations has consistently been a major factor impeding action. Furthermore, the involvement of HIV positive people in policymaking and programme delivery is essential to success, and such involvement requires partnership and respect, not sympathy and tolerance. This is according to an article by the International HIV/AIDS Alliance (2003) that presents an assessment of the successes and failures of the global response to AIDS from 1993-2003.
A United Nations plan to provide three million HIV-infected patients in Africa with anti-retroviral drugs by 2005 is in danger of collapsing owing to lack of funds, UN and World Health Organisation officials said. Some countries, particularly the United States, are balking at supporting the project, Aids workers say, partly because the plan intends to use a form of medicine called fixed-dose combination antiretroviral drugs whose use is opposed by large pharmaceutical companies.