AIDS successes bring new challenges
In a few short years, paternalistic Western scepticism about Africa’s ability to run large-scale antiretroviral treatment programmes has been swept away by widespread evidence of successful ARV programmes.
‘To my shame, I was one of those who said that antiretroviral therapy could not be delivered in sub-Saharan Africa in 1999,’ admitted Professor Anthony Harries, who is now working for Malawi’s health ministry on its ARV programme.
The massive influx of Pepfar money ‘ $15-billion over five years ‘ to assist the 15 worst affected countries in Africa, Asia and the Caribbean to deal with AIDS has clearly made a difference.
In three short years, Pepfar has helped to get 561 000 people in the 15 countries including South Africa to get antiretroviral treatment.
‘Communities that have been in total despair, believing that they are headed for death, have been transformed after six months of ARV treatment to have hope,’ said Dr Mark Dybul, acting US Global AIDS Co-ordinator.
Research from ARV programmes in six African countries showed that patients’ CD4 counts (measure of immunity in the blood) doubled after only six months on treatment.
After a year on ARVs, the South African patients studied ‘ all from rural Eastern Cape ‘ had more than tripled their CD4 counts from a very low average of 72 to 301.
But success brings its own challenges, and the huge scale of the treatment programme is putting strain on health systems all over Africa.
In June 2004, Malawi had 4000 patients on ARV treatment. By March this year, it had almost 50 000 ARV patients ‘ and 94% were now fit to work. It plans to almost double this figure by the end of the year. In four years’ time, it aims to reach almost a quarter of a million people ‘ about half of those who need ARVs in the country.
Malawi has been able to expand so fast because its programme relies on simplicity, says Harries. Patients are diagnosed according to the symptoms that they present with, rather than by complicated laboratory tests.
In addition, Malawi’s drug regimen is simple. Patients take one pill called Trimune twice a day. Trimune is a generic that combines all three brand-name ARVs into one.
Even so, said Harries, there simply aren’t enough people, space in clinics and hospitals or pharmacies to cope with the demand.
‘We are going to have to reduce patient visits to once every two or three months, decentralise treatment to health centres and get a lower cadre of staff to manage ARV delivery,’ said Harries.
His view was echoed by people from all over the continent. Dr Alex Coutinho from The AIDS Service Organisation in Uganda said his organisation had trained lay people as clinical officers to monitor people on ARV treatment as there weren’t enough healthworkers in the country.
South African Health Minister Dr Manto Tshabalala-Msimang took numerous swipes at Pepfar when she opened the conference. But her assertion that donor funds should be directed to building Africa’s health systems was well received.
‘Vertical financing is not sustainable. Sustainability lies in the extent to which countries can build and maintain health systems. It is only when funders support efforts to build well functioning health systems that we can truly speak of sustainability,’ said Tshabalala-Msimang.
Pepfar has also been criticised for slanting its funding for HIV prevention towards the A and B of the prevention ABC mantra ‘ ‘Abstain, Be faithful, Condomise’.
In addition, about one-fifth of its beneficiaries are religious organisations, which has opened Pepfar up to criticism that President Bush is using the plan to promote a conservative religious agenda.
But Dybul defended Pepfar’s AB bias, saying that in the past condom use had been over-emphasized.
‘There is consensus that the ABC approach is an effective prevention strategy. But there has been a tremendous imbalance in favour of condoms,’ said Dybul.
‘It is completely untrue that we are only promoting abstinence and be faithful. We have doubled condom provision since 2001, but we are doing this in the context of abstinence and fidelity.’
However, a number of researchers reported on difficulties in promoting abstinence and fidelity to young people.
‘If a girl abstains and boys know that, they want to rape that girl because they know that she does not have AIDS. The bad thing is that they want to kill that girl after rape,’ said a primary school girl from the Valley of a Thousand Hills outside Durban.
A schoolboy from the same area said peer pressure made sticking to one partner very difficult: ‘Colleagues ask you about your relationships and the number of girlfriends you have. When you tell them that you don’t have a girlfriend or you only have one girlfriend they would just laugh at you, saying you are stupid.’
The two were both part of a survey of 1 766 primary school children in Valley of a Thousand Hills.
‘Youth [taking part in the survey] generally agreed that A and B are feasible behaviours for youth under 14 and grandparents, but not for adolescents or the adult population,’ reported researcher Tobey Nelson.
Kenyan students from the University of Nairobi reported that they found ‘abstain’ and ‘be faithful’ to be contradictory messages. Despite an ABC campaign on campus, students were not changing their behaviour.
African delegates also raised anxiety about the fact that Pepfar is a five-year programme.
‘Uganda needs the support of Pepfar for ten years or more,’ said Coutinho.
Dybul’s reply was that governments worked in five-year cycles, and that Pepfar had the support of both Republicans and Democrats and ‘there is no question in anyone’s mind that the US will continue to support the fight against AIDS’.
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