UNIVERSITY OF PENNSYLVANIA - AFRICAN STUDIES CENTER
AFRICA ACTION Africa Policy E-Journal June 15, 2003
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.africaaction.org/docs03/fund0305.htm and http://www.fundthefund.org
SOUTH AFRICA: Optimism over possible ARV rollout
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.
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
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 HIV- positive 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".
To view a PlusNews web special on the issue: http://www.irinnews.org/webspecials/hiv-in-prisons
Date distributed (ymd): 030615 Region: Southern Africa
Issue Areas: +health
Message-Id: <200306152331.h5FNVjH19223@marduk.africapolicy.org> From: "Africa Action" <email@example.com> Date: Sun, 15 Jun 2003 19:32:39 -0500 Subject: Southern Africa: Steps Forward on AIDS Treatment
Editor: Ali B. Ali-Dinar
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