Following the ‘€˜worst case scenario’€™

Tears choked the internationally acclaimed AIDS economist’€™s voice as he tried to tell a recent conference that, in six years’€™ time, a quarter of all Lesotho’€™s children will be orphans.

Later Professor Alan Whiteside, somewhat embarrassed by his tears, said: “It’€™s just that I’€™ve been doing this work for 14 years now and it’€™s getting to me. Fourteen years and still people are not listening,” he said afterwards.

I wonder as I write this, how many readers have skipped this story, tired of yet another AIDS feature, although the worst effects of the epidemic have yet to manifest themselves.

Many people seem to feel that, since the South African Cabinet announced in November 2003 that antiretroviral (ARV) drugs would be available in public health, the AIDS struggle is now over.

But as Professor Jerry Coovadia cautions, “there is no magic silver bullet”.

The world’€™s most complex viral epidemic is far from beaten and our success depends largely on radically improving prevention campaigns.

Fourteen years ago, Metropolitan actuary Peter Doyle forecast various scenarios for HIV/AIDS in this country. Tragically, we have followed his “worst case scenario”. After an exponential explosion of HIV infections between 1994 and 1998, new infections are still increasing but at a far slower pace.

HIV infection of pregnant women at antenatal clinics has risen from 0.7% in 1990 to 27.9% in 2003. At a micro level, in clinics at Hlabisa, northern KwaZulu-Natal, only 4.2% of people were HIV positive in 1992. This figured then doubled every year for three years.

As the virus has a delayed reaction, steadily undermining a person’€™s germ-fighting T-cells, those infected with HIV in the late 1990s have only started to fall sick recently. They are now swamping the understaffed state hospitals, crowding out HIV negative patients, particularly the elderly and those with chronic diseases.

Minister Manto Tshabalala-Msimang herself has admitted that health professionals’€™ lack of knowledge about ARV management has slowed down the provision of these drugs. Only about 11 000 of the half a million people estimated to need the drugs are getting them.

By 2002, AIDS related illnesses were responsible for 40% of deaths, according to the Medical Research Council (MRC). The patterns of death have been horribly distorted. More than triple the number of women aged 20 to 30 and double the number of men aged 30 to 40 are dying then normal for a country such as ours.

The best we can aim for now, says KwaZulu-Natal AIDS expert Professor Salim Abdool Karim, is for the infection graph to plateau.

“If HIV incidence continues to increase, it means that our prevention efforts are not working. If the incidence rate starts tailing off but there isn’€™t an effective antiretoviral programme, it means too many people are dying. A plateau means that prevention and treatment are working together.”

A huge barrier to getting prevention and care to dovetail, however, is that there is still denial about the extent and the impact of the epidemic.

The residue from President Thabo Mbeki’€™s AIDS denial remains lodged within officialdom, resulting in distorted messages and a less-than-enthusiastic response to HIV/AIDS initiatives.

Government spin doctors’€™ claims that the official HIV/AIDS programme has always been premised on HIV causing AIDS is technically correct. But their more recent spin that the conflict around AIDS over the past few years was caused by poor communication is a distortion.

Four years ago, Mbeki declared in Parliament that “a virus cannot cause a syndrome”. He also said “if any Members of Parliament are taking these [antiretroviral] drugs, they need to have a look at that otherwise they are going to suffer negative consequences”.

These remarks put Mbeki squarely in the camp of the AIDS “dissidents”, who do not believe that HIV causes AIDS and that that antiretroviral drugs are a health danger.

Since then, Mbeki has simply kept quiet rather than repudiating his previous position. Those keen to be in the president’€™s good books are unsure of what Mbeki now thinks about HIV/AIDS and are thus unlikely to campaign vigorously against the epidemic in case they offend their boss.

This has led to a malaise in government. While the Treasury and the Auditor General may tut-tut about provinces misspending or under-spending their AIDS budgets, there is little political censure for weak HIV/AIDS programmes.

While factionalism has taken its toll on the AIDS “dissidents” and one key dissident has quit his job amid psychological problems, diehard Anita Allen laid a complaint with the Public Protector after Cabinet decided to provide antiretroviral drugs in the public sector.

Her complaint, which argued that Cabinet’s decision was unconstitutional and based on the “unproven proposition” that HIV causes AIDS, was recently rejected. Nonetheless, the dissidents have succeeded in planting doubt about HIV and ARVs in the minds of people who are already in denial.

Deli Sindane, who has been on ARVs for 20 months, says she was initially extremely sceptical of the drugs as conventional wisdom in her area near Durban was that they were dangerous enough to kill you.

Certainly, ARVs do have side-effects. Long term side effects include high cholesterol, liver and kidney problems, lipodystrophy (wasting in certain areas) and heart disease. But the alternative is death.

In San Francisco during the peak of the AIDS epidemic in the early 1990s, 1 800 people were dying each year. By 1997, access to triple therapy (three ARV drugs used in combination) had become more widespread, and the death rate plunged by two-thirds.

In the next decade, we can only hope for more scientific advances.

Already a new class of ARV drugs called entry inhibitors have been developed. These block the virus from entering and destroying cells instead of simply interfering with its replication once already inside cells, as the current ARV drugs do.

Less toxic than the older drugs, entry inhibitors are currently only available as intravenous injections. But a large clinical trial of an oral version of the drugs is underway and if this is successful they could become widely available from 2007.

There are high hopes that a microbicide or vaginal barrier gel will be developed to enable women to protect themselves without relying on male partners to wear condoms. While a phase three (efficacy) trial of a microbicide, Carraguard, is soon to start in South Africa, southern Africa’€™s penchant for dry sex may mean it has limited popularity.

An AIDS vaccine is proving slow and elusive. While 30 vaccine candidates are in clinical trials (including the Alphavax one that started this year in South Africa) they are all in phases I or II (safety trials). The earliest data an efficacy is expected is 2008, according to the International AIDS Vaccine Initiative (IAVI).

IAVI also notes that there are still huge gaps in the research as all the vaccine candidates are based on the same premise, that it may be possible to elict “cell-mediated immunity”.

At the top end of the scale, Harvard’€™s Dr David Scadden has been working on stem cell research aimed at rebuilding people’€™s immune systems to be able to respond to HIV.

Stem cells make all kinds of blood cells including T cells that fight infection. Crudely, what Scadden is trying to do is to re-engineer the T cells to recognise and fight HIV ‘€“ what he describes getting them to operate like “an intracellular vaccine”.

So far, he and his team have established that people who have had the re-engineered blood cells put back into them can survive but they have yet to prove the anti-viral effect of these cells.

But the research is complicated, expensive and politically fraught. So, despite a promising start, Scadden has had to abandon his latest trials after his corporate sponsors withdrew.

For us in the furthest tip of Africa, most devastated by HIV and AIDS, as we look to the next decade our best hope lies in visionary leadership, a responsive health infrastructure, compliant ARV takers and a compelling prevention programme to protect future generations ‘€“ all of which are currently lacking.

E-mail Kerry Cullinan



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