Moving therapy to frontline of AIDS war

Just a decade ago, treatment for HIV/AIDS did not exist. A positive HIV test meant certain -- and imminent -- death for every man, woman and child. Today, however, therapy relying on anti-retroviral drugs (ARVs) which attack the virus that causes AIDS can transform the sure death sentence into a more chronic condition, enabling those suffering to live much longer, healthier lives. Technically, anti-retroviral therapy is feasible throughout the world. The cost of the medicines has come down dramatically.

Even in the poorest parts of Africa, the possibilities are already evident. In Khayelitsha, an impoverished township in Cape Town, South Africa, a provincial government-run programme was launched in 1999 to prevent mother-to-child transmission of HIV, using Zidovudine, an ARV. Two years later the programme broadened to include more comprehensive anti-retroviral therapy (ART), in response to very high death rates among patients. Most were very sick when they began therapy, but within six months their counts of CD4 T cells (which orchestrate the body's immune response) rose dramatically, and after nine months, 88 per cent of patients were still alive, with few serious side effects.

Getting an anti-retroviral prescription in Botswana.

Photo: World Health Organization/Eric Miller

Comparable results were seen in another pilot ARV programme at a small rural health centre attached to Masaka hospital in southern Uganda, funded by the US-based AIDS Healthcare Foundation. Of the 53 original patients in the programme, three died and three experienced minor side effects. The rest improved dramatically.

"When death is around you," commented one doctor in South Africa, people "have no trouble" adhering to the therapy's regimen of taking ARVs. "ARV therapy can be delivered successfully by an NGO-driven programme to an informed and educated rural patient population," he concluded.

These results demonstrate that the weakness of Africa's health systems is not an insurmountable obstacle to delivery of ARV therapy, even in rural areas. Yet, experts point out, it remains essential to strengthen public health care systems with additional government and donor funding.

A small beginning

ARV treatment programmes across much of Africa are still in their infancy. Botswana is treating about 7,500 people, Nigeria 15,000, Uganda 10,000, Malawi 3,000, Cameroon 6,000 and Senegal 1,500. The overwhelming majority of those receiving ART live in cities and towns, although a few countries, such as Uganda and South Africa, are trying to extend treatment into rural areas.

Some of the ART programmes provide the drugs free of charge (as in Botswana and Ghana), but most are subsidized. The Zambian government, for example, is currently rolling out subsidized ARVs to 10,000 of the 300,000 people who need them, at a cost of about $5 per month. Kenya has just announced that by 2005, the government will provide free ARVs to 140,000 individuals living with HIV-AIDS.

A handful of countries are going a step further by setting up factories to produce generic ARVs. In Zambia, a joint venture between two international pharmaceutical companies and a local firm will start producing generic medicines before June 2004. In Uganda, a local company is in the process of setting up a factory to manufacture ARVs before the end of 2004 for the country's estimated 100,000 people living with HIV/AIDS, aiming to provide the drugs at a cost of less than 50 cents per day.

Of the more than 4 million Africans now requiring anti-retroviral treatment, only 70,000-100,000 are receiving it. With the drastic fall in drug prices, there is a real opportunity to expand treatment.

Of the more than 4 million Africans estimated to now require treatment, only about 70,000-100,000 are currently receiving it. With the drastic fall in the price of the drugs and the encouraging results of existing programmes, some health and development practitioners in Africa see a real opportunity to greatly expand the scale of ARV treatment, accelerate HIV prevention efforts and change the course of the epidemic.

The alternative is alarming. "If we don't find ways of providing ART in a sustainable manner, we may have to face the collapse of socio-economic systems across Africa," argues Prof. Desmond Cohen, a former director for HIV and development at the UN Development Programme who currently is assisting countries to scale up their treatment and care responses.

In recognition of the urgency, the UN's World Health Organization (WHO) in 2003 launched a "Treat 3 million by 2005 Initiative." It aims to provide 3 million people living in developing countries with ART and access to related medical services by the end of 2005 (see article "Massive '3x5' AIDS campain gears up").

Buying time, easing burdens

Improving Africans' access to these life-saving drugs is not only a moral imperative, but makes good economic sense. "ART buys time, human resources, memory, skills and the future," Prof. Tony Barnett of the London School of Economics, who has been working on HIV/AIDS since 1988, toldAfrica Recovery.

By prolonging lives, ART significantly reduces the worst short-term effects of the epidemic. People living with AIDS will remain productive for longer and be better able to provide their families with food, shelter, education, health care and socialization.

There will be fewer orphans and vulnerable children -- a growing burden in Africa today. To date, a staggering 12 million children have lost one or both parents to the epidemic. In parts of Zimbabwe and Zambia some foster families have become impoverished and are no longer willing to take in orphans. Treatment therefore can relieve some of the pressure on Africa's traditional socio-economic safety nets.

Access to treatment also will help stem erosion in the capacity of formal and informal institutions, especially disruptions in the delivery of basic services such as health, education and agricultural extension because of high levels of illness and death among their personnel. Across Africa, ministries of agriculture and other rural institutions are losing staff and finding it harder to address serious food security and rural development problems.

Those working with people living with AIDS recognize that treatment is not just about improving the health of individuals, but also the survival and socio-economic well-being of entire households and communities. In Mbabane, Swaziland, at a meeting in August 2003 with the Swaziland AIDS Support Organization, participants emphasized that the epidemic affects every household in the country, urban or rural, rich or poor. Two founding members of the Network of Zambian People Living with HIV/AIDS in Lusaka made a similar point. Access to ART services, they said, should be the top priority not only for people living with AIDS, but also for their families and for their countries, given the magnitude of young adult morbidity and mortality in most of East and Southern Africa and parts of Central and West Africa.

Costs and benefits

Some economists have long argued that improving access to ARVs is not a sound investment of scarce resources in Africa, and that alternative uses for those funds would bring greater social benefits. That argument was based on an often-crude calculation of the costs of ARV treatment and related services.

This approach overlooks some of the "hidden" benefits of treatment. For example, managing patients on ART may be less costly in the long term than managing patients not receiving therapy. Many such patients are frequently ill with opportunistic infections, which are often difficult to diagnose and treat and may require repeated hospitalizations. In contrast, patients on ART rapidly experience dramatic improvements in their health. As a doctor in Botswana argued, "With the time we spend on one patient who is in intensive care, we could treat 5-10 patients who are not so ill."

Therefore, a substantial percentage of the costs incurred by ARV purchases will be offset by drops in hospitalizations and the time of health care personnel, as already demonstrated in Brazil. That is likely to be the case in parts of Southern Africa as well. South Africa, for instance, now spends about $400 mn on care and treatment of people with AIDS, according to a 2003 study by the University of Cape Town and Médecins sans Frontières.

In South Africa, Uganda and other African countries that have begun treatment programmes, therapy has shown the potential to restore hope for the future -- provided quick and decisive measures are taken.

Moreover, the long-term economic costs must be factored into the equation. These include losses in economic growth rates ranging between 0.3 per cent and 1.5 per cent annually, because of lost production, higher health costs and other impacts. Although they are difficult to quantify, there also are longer-term costs related to social reproduction, declines in the capacity of institutions and losses in the knowledge and skills of the poor over several generations.

An incentive for testing

ARVs are also proving to be a powerful instrument for HIV prevention. Until recently, an argument frequently heard in Africa was: "Why should anyone test for HIV if there is no access to treatment?" According to a 2003 study by Médecins sans Frontières and WHO of the ARV treatment programme in Khayelitsha township in South Africa, that experience demonstrates that treatment promotes prevention because it:

• motivates people to want to know their sero-status -- without treatment as an option, knowledge that one is HIV-positive offers little more than stigmatization
• promotes openness and reduces stigma, as HIV is no longer an inevitable death sentence
• helps keep families intact and economically stable, thereby protecting the most vulnerable (women and children) and minimizing the number of people at risk.

"Prevention and treatment are complementary, not competing priorities," Joint UN Programme on HIV/AIDS (UNAIDS) Executive Director Peter Piot has argued. "Prevention secures the future. Treatment saves lives and money immediately." And by accelerating HIV prevention efforts, treatment also is an investment in the future.

Beyond the health sector

So far, support for scaling up ARVs has come mostly from the health sector and has focused on providing treatment in urban areas. But the magnitude of the task of delivering ART to all those who need it, or at least to the WHO target of 3 million people by 2005, in urban as well as rural areas, is of such a scope that Africa's health care systems cannot undertake this alone. Many of the constraints to the provision of ART are socio-economic and socio-cultural, including the low status of women, poverty, food insecurity, and the stigma attached to HIV/AIDS, which prevents many people from seeking treatment.

The challenge is to tackle access to ARVs not only as a medical issue, but also as a multi-sectoral, development priority that touches upon all sectors, from agriculture and rural development to industry and education. This gap can be filled when those outside the health field act to support access to these drugs not only for treatment purposes, but also to minimize the effects of the epidemic on their particular sector. Botswana's success in bringing together various ministries and institutions for HIV prevention at the district level points towards such an approach for treatment as well.

One response so far to the ravages of AIDS on the productivity of rural communities has been to promote labour-saving agricultural and domestic technologies, such as inter-cropping to reduce weeding time, lighter ploughs that can be used by youth, women and the elderly, and fuel-efficient stoves. By themselves, however, such technologies may not be of much help to households with chronically ill young adults whose first priority is caring for ailing family members, managing their own illnesses and seeking treatment for opportunistic infections.

In such conditions, argued Prof. Barnett, "It is ART which is labour-saving." With therapy, the health of household members would improve sufficiently to enable them to adopt new technologies. More broadly, the effectiveness of agricultural programmes' core activities could be enhanced if they linked labour-saving technologies and other agricultural services with health care and ARV therapy through partnerships with public health systems and community organizations.

ARV treatment can also be linked with focused food security and nutrition measures. Some donor agencies, such as the UN's World Food Programme (WFP), are already moving in this direction. "WFP comes into the picture because treatment and nutritious food go together," Ms. Robin Jackson, head of WFP's HIV/AIDS Unit, told Africa Recovery. "People living with HIV/AIDS who are on ART need access to food if the treatment is to be effective."

The organization is giving food aid to tuberculosis patients, one in three of whom are infected with HIV; the food makes it easier for them to continue and complete medical treatment. WFP is also participating in preventing mother-to-child transmission programmes and providing food aid packages for orphans in school.

18-year-old heads her family in Mozambique, after parents died of AIDS.

Photo: AFP/Getty Images/Alexander Joe

Primary health care systems in rural areas and poor urban communities can be strengthened by establishing partnerships with specialized NGOs that deliver ART. The success of the Khayelitsha programme has been attributed largely to community involvement (in selecting the patients for ARV therapy), educating patients to take responsibility for their own treatment and restoring hope among a community devastated by HIV/AIDS.

"What is important about the Khayelitsha model is that it is providing ART, successfully, in partnership with the community," argues Prof. Cohen. "This approach can also serve to access rural populations and strengthen the ways in which these [efforts] address the underlying issues that contribute to HIV infection, such as poverty and food insecurity."

ARV therapy, by itself, is not the solution to the AIDS crisis. According to Ms. Jackson of the WFP, even if the 3 million people who are targeted for ARV treatment are reached, "another 15 million dependants and relatives as well as those not receiving treatment will continue to suffer from the knock-on effects of the epidemic. These people should not be forgotten."

The experience so far indicates that ART can be an integral part of the solution -- along with prevention, care, mitigation of the epidemic's adverse impacts and, on the medical side, the development of vaccines and other remedies. Therapy will prolong the lives of those living with HIV/AIDS, alleviate suffering, save money and protect future generations by strengthening prevention.

At a time when many young rural Africans are wondering why they should plant crops if they may soon die, hope is scarce. But in South Africa, Uganda and other African countries that have begun treatment programmes, therapy has shown the potential to restore hope for the future -- provided quick and decisive measures are taken. Inaction and delay could well plunge African societies into a downward spiral from which they may not recover.