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Southern Africa: Steps Forward on AIDS Treatment
AFRICA ACTION
Africa Policy E-Journal
June 15, 2003 (030615)
Southern Africa: Steps Forward on AIDS Treatment
(Reposted from sources cited below)
This posting contains several recent reports from the UN's
Integrated Regional Information Networks (IRIN). Two report on
positive steps: the extension of antiretroviral treatment in
Western Cape province in South Africa, and Namibia's decision to
produce antiretroviral drugs locally. The third summarizes a longer
series of reports on HIV/AIDS in prisons in southern Africa.
Meanwhile, policymakers in South Africa and globally will be making
key decisions in the next few weeks that will determine whether
such steps as those in the Western Cape and Namibia can be extended
more widely. The South African cabinet is still considering an
advisory report on providing public financing for antiretroviral
treatment. European countries meeting in Greece this week will
reportedly consider whether or not to increase funding for the
Global Fund to Fight AIDS, TB, and Malaria, and major donors to the
fund also meet in mid-July. The U.S. Congress still has to decide
whether to appropriate funds to match the authorization bill it
passed for $3 billion a year, including up to $1 billion a year for
the Global Fund.
The Global Fund Observer (GFO, http://www.aidspan.org) reports that
recent new pledges may provide the Fund with only about one-third
of the amount needed to fund the expected third round of
applications to be approved this October. The GFO says that
funding the Round 3 grants would be possible if European countries
decided to convert multiyear pledges into immediate grants, and if
the U.S. Congress voted to appopriate funds for 2004 at a level
closer to their $1 billion authorization target than to the Bush
administration's budget request for only $200 million.
Also see:
http://www.africafocus.org/docs03ej/fund0305.php>
and
http://www.fundthefund.org
+++++++++++++++++end summary/introduction+++++++++++++++++++++++
SOUTH AFRICA: Optimism over possible ARV rollout
http://www.irinnews.org
JOHANNESBURG, 10 June (IRIN) - The Western Cape was the first
province to defy South African government policy by providing
AIDS drugs to HIV-positive pregnant women in the public health
sector.
Two years later, the rollout campaign has achieved universal
coverage and now babies and children living with HIV/AIDS are
also to get access to treatment.
The next step will be to provide antiretrovirals (ARVs) for all
people living with HIV/AIDS through the public health sector
"soon", Western Cape health minister, Piet Meyer, said last week.
In March 2003 the province announced that all HIV-positive
pregnant women could access the antiretroviral drug, Nevirapine,
at their nearest clinic.
This meant that even women in hard-to-reach rural communities
could prevent mother-to-child transmission (PMTCT) of HIV by
visiting the monthly mobile clinic, Western Cape health director
general, Fareed Abdullah, told journalists during a workshop on
anti-AIDS drugs recently.
The uptake of women into the programme has been very high, with
between 90 percent and 95 percent of pregnant women in and around
Cape Town enrolled in the PMTCT project, Cape Town's Director of
Health Dr Ivan Toms told PlusNews.
In the rest of the province, 90.9 percent of women accepted
voluntary counselling and testing in 2002.
ARV ROLLOUT
The challenge for the provincial government is to replicate this
success when implementing a treatment plan for adults.
"We need to put between 50 percent and 60 percent of the people
living with HIV/AIDS, who need drugs, on treatment, and we need
to do it right," Abdullah said.
But introducing ARV treatment was "not an emergency", it needed
"planning and support". "You can discuss and debate when to
access treatment, but at least have a sense of strategy and
direction," he urged.
The first step would be through PMTCT "Plus". Previously, PMTCT
initiatives focused on infants, with very little being done for
the rest of the family. But mothers and other family members
would soon be able to get ARV therapy, care and support services.
"It has just been agreed that Cape Town will introduce this
[PMTCT Plus] in Langa [one of the city's townships] for up to
1,000 people. There will be a commitment to provide ARVs for
life, to ensure the project's sustainability," Toms said.
Although a national ARV rollout was "relatively close", it was
important to have an effective health system in place first, he
noted.
Nevertheless, tuberculosis (TB) remains the province's biggest
problem. The province had the highest TB rate nationally, and one
of the highest in the world. About half the 21,000 TB cases in
Cape Town in 2002 were also HIV-positive.
One of the biggest hurdles would be to effectively integrate TB
and HIV/AIDS programmes, as the rising HIV prevalence is likely
to increase the number of deaths due to TB. This had led to the
recent introduction of voluntary HIV counselling and testing in
TB clinics.
The TB programme's "good cure rate" would be an invaluable lesson
for future ARV programmes - particularly in treatment adherence,
Toms said.
Consequently, the province was well-positioned to "take things
forward" in terms of treatment, he added.
Findings from the Medecines Sans Frontieres' (MSF) ARV therapy
pilot programme in the Cape Town township of Khayelitsha
demonstrated that treatment campaigns were possible in poor
communities, and the provincial health authorities had taken note
of the project's success.
For Abdullah "the greatest complexity lies in the importance of
adherence", as opposed to logistics. Drug compliance is critical
for antiretroviral regimens, as it can prevent or forestall the
development of drug resistance. "In the last two years,
Khayelitsha has shown [us] not to exaggerate the meaning of
'complex' - it can be done."
THE WAY FORWARD
According to projections, the Western Cape will be providing
treatment to 30,000 HIV-positive people by 2010. Before this
happens, compromises would have to be made. The province will
start off with one ARV site per health district, taking budget
constraints into account.
Staffing was a potential "Achilles heel" Abdullah noted. "Staff
will always be a concern because budget constraints mean staff
constraints," Toms pointed out.
Until the rollout takes place, issues such as overcoming stigma
and discrimination would also have to be addressed, as this could
prevent many people living with HIV/AIDS from accessing the
drugs, Toms said.
"Another thing we can never let up on is prevention. The city
plans to distribute 18 million condoms this year - but this is
still a drop in the ocean," he added.
Meanwhile, the South African cabinet is expected to discuss a
national ARV costing report this week, ahead of a meeting between
AIDS lobby group the Treatment Action Campaign and the National
AIDS Council on 14 June.
AIDS activists hope recommendations handed down by the report
will end months of a bitter stand-off between them and the
department of health over its refusal to implement a treatment
policy.
But the Western Cape's health department is optimistic. "When
government makes the decision to provide treatment, all hands
will need to be on deck," Abdullah said.
NAMIBIA: Anti-AIDS drugs to be produced locally
JOHANNESBURG, 11 June (IRIN) - HIV-positive Namibians could soon
be able to access cheaper anti-AIDS drugs after the government
announced plans to support the local manufacture of generic
medication in the country.
Speaking during discussions between visiting UN Special Envoy on
AIDS, Stephen Lewis, and a group of ministers, Health Minster Dr
Libertinah Amathila said cabinet had last week given a local
pharmaceutical company the go-ahead to produce antiretroviral
(ARV) drugs.
According to a report on the meeting, Lewis said he saw no reason
why a plant to manufacture ARV drugs in Namibia should not
succeed.
The AIDS Law Unit of the Legal Assistance Centre welcomed the
move. "For the many thousands of Namibians who are HIV positive
and who, in many cases, already desperately require treatment,
this announcement provides hope that Namibia can finally begin to
turn the deadly tide of this epidemic," the lobby group said in a
statement.
Despite a recent spate of price cuts, the cost of ARVs remained
"way out of reach" for most Namibians. "You can expect to pay
between 1,600 and 2,500 Namibian dollars (US $203 to $317) a
month, depending on the regimen," Michaela Clayton, project
coordinator of the AIDS Law Unit, told PlusNews.
While generic medication had only recently been obtainable in
government medical stores, it was still difficult to determine
the extent to which they were broadly available to the public,
Clayton pointed out.
Local manufacture of ARVs would make a "huge difference" in
access to affordable treatment - not just for Namibia, but for
the Southern African region, she noted.
"Producing generics locally is a bold step, and this will serve
as an example to other governments," she added. Few Southern
African countries have taken advantage of the World Trade
Organisation's Doha declaration, which allows developing
countries to use generic drugs in times of health crises,
overriding the patents held by major pharmaceutical companies.
SOUTHERN AFRICA: The challenge of HIV in prisons
To view a PlusNews web special on the issue:
http://www.irinnews.org/webspecials/hiv-in-prisons
JOHANNESBURG, 11 June (IRIN) - The jail doors that slam behind a
newly arrived inmate are likely to open again at some point in
the future and release the ex-convict back into society. The
problem of HIV/AIDS in prison, and the wider issue of penal
reform, are therefore questions that should concern us all.
Prison conditions in most countries of the world are ideal for
the transmission of HIV. "They are frequently overcrowded. They
commonly operate in an atmosphere of violence and fear. Tensions
abound, including sexual tensions. Release from these tensions,
and from the boredom of prison life, is often found in the
consumption of drugs or in sex," a UNAIDS "Best Practice" report
noted.
These are conditions that some people face more than once during
the course of their lives, entering and leaving prison
repeatedly. In South Africa, over 40 percent of prisoners are
incarcerated for less than a year, with only two percent serving
life sentences, according to a study by the Pretoria- based
Institute for Security Studies (ISS). On average, 25,000 people
are released from South African prisons and jails each month.
HIGH RATES OF HIV
HIV prevalence in prisons is usually higher than in the
population at large. As a result of the poverty and deprivation
that helps drive criminality and HIV/AIDS, many of those inmates
who are HIV-positive in prison were already infected on the
outside.
"Poverty is a defining characteristic of both prisoner and HIVpositive
populations alike," the ISS report, "HIV/AIDS in Prison:
Problems, Policies and Potential", points out. But rather than
acceptance of the problem, measures can be taken to reduce the
transmission of HIV, and help delay the emergence of AIDS-related
illnesses.
"Policies to address HIV transmission in prison cannot be
effective without immediate and urgent prison reforms," the
report stressed. "Overcrowding, corruption and gangs are the
primary culprits behind rape, assault and violence in prisons,
and this environment is horrifying, even without the risk of HIV
infection."
HIGH RISK BEHAVIOUR
The main types of high-risk behaviour in prisons are contaminated
needles used by injecting drug users - which is not a major
problem in African countries - and/or instruments used for
tattooing. Unprotected sex between men is another important
factor.
"The extent of sexual activity in prisons is difficult to
determine because studies must rely on self-reporting, which is
distorted by embarrassment or fear of reprisal. Sex is prohibited
in most prison systems, leading inmates to deny their involvement
in sexual activity. Sex in prison usually takes place in
situations of violence or intimidation, thus both perpetrators
and victims are disinclined to discuss its occurrence," the ISS
study noted.
In women's prisons where there are male prison staff, sex between
men and women may also take place, UNAIDS pointed out, creating a
risk of HIV transmission.
Homosexual activity is illegal in every southern African country
with the exception of South Africa. However, according to UNAIDS,
8.4 percent of men in the Zambian prison of Kamfinsa reported
anal sex in a study in 1995, with the true figure likely to be
higher. A 1999 Penal Reform International study of Zomba prison
in Malawi reported respondents as estimating that between 10 to
60 percent of prisoners had participated in homosexual activity
at least once.
Three aspects of man-to-man sexual activity in prison make it a
high risk for HIV transmission: anal intercourse, rape and the
presence of sexually transmitted infections (STIs). Related
problems in prisons across Southern Africa include overcrowding,
shortages, corruption, and the presence of juveniles alongside
adult prisoners.
The Zomba study noted that those who served as the "receptive
partner" were usually: "recently detained, either juveniles or
young adults, who have no blanket, soap, plates or food. They
have no relatives from the outside to help them and care for
them, they are in physical need and confused by their recent
detention, and they turn to somebody to care for them. The ones
they usually turn to are those who have outside supplies. The
relationship between them was described as similar to that
between a poor prostitute and a rich client."
The report also noted the existence of "prostitution rings", in
which guards were involved in smuggling juveniles into the adult
blocks, sometimes for as little as 30 US cents. The practice was
assisted by inadequate supervision and segregation of juveniles
from adult inmates.
The appalling physical conditions of most prisons in Southern
Africa, along with inadequate nutrition and health services,
exacerbates the incidence of AIDS. Particularly serious is
tuberculosis (TB), which can easily spread in overcrowded prison
conditions. People with HIV are especially vulnerable to TB, and
HIV-positive people can transmit the disease to those not
infected with HIV, the UNAIDS report warned.
The potential for the spread of HIV is also increased by a lack
of information and education, and a lack of proper medical care.
STIs, if left untreated, can greatly increase a person's
vulnerability to HIV through sexual contact, UNAIDS noted.
WHAT TO DO?
Rather than accepting the reality of sexual activity and the
attendant risks, most prison authorities in Southern Africa
refuse to provide condoms for inmates in the belief that it will
encourage homosexuality. Attitudes of denial will have to change
if societies want to see the rate of HIV infection - inside
prison and outside - decrease.
The UNAIDS position is clear. "Recognising the fact that sexual
contact does occur and cannot be stopped in prison settings, and
given the high risk of disease transmission that it carries,
UNAIDS believes that it is vital that condoms, together with
lubricant, should be readily available to prisoners. This should
be done either using dispensing machines, or supplies in the
prison medical service."
Even in South Africa where the provision of condoms is policy, in
the prisons themselves, access is still circumscribed by issues
of shame and censure.
"The impact of HIV/AIDS on prisoners is most visible in the
rising number of deaths in prison each year," the ISS report
cautioned. "What must be envisioned is the positive impact
prisoners can have on HIV/AIDS."
The study recommends aggressive behavioural change interventions,
transforming cells into classrooms, in which gang leaders are
co-opted as peer educators. It also calls for better health
education and health services, enabling the prison authorities to
make "significant contributions towards an AIDS-free generation
in South Africa".
+++++++++++++++++++++Document Profile+++++++++++++++++++++
Date distributed (ymd): 030615
Region: Southern Africa
Issue Areas: +health
The Africa Action E-Journal is a free information service
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commentary and reposted documents. Africa Action provides this
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