Africa: AIDS & Financial Abstinence, 02/11/04

Africa: AIDS & Financial Abstinence

AfricaFocus Bulletin
Feb 11, 2004 (040211)
(Reposted from sources cited below)

Editor's Note

"You might think that the industrial nations would compensate for a decade of financial abstinence by embracing the Global Fund as the obvious vehicle for resource-constrained countries. But that hasn't been the case. At this moment in time, the Fund is several hundred million dollars short for this year, and almost three billion short for next."

Stephen Lewis, UN Special Envoy for HIV/AIDS in Africa, went on to note that the Bush administration has only asked for $200 million for the Global Fund for 2005. This is $350 million less than the sum approved by Congress for 2004 and a full billion dollars short of what would be the fair contribution of the United States.

This issue of AfricaFocus Bulletin contains excerpts from the text of Lewis' February 8 speech in San Francisco to the 11th Conference on Retroviruses and Opportunistic Infections [the full text is available at http://www.africafocus.org/docs04/hiv0402a.php].While targetting the continued financial abstinence of the rich countries in the face of millions of deaths, the outspoken envoy also denounced the absence of any real change in women's lives despite the rhetoric of gender equity.

Another AfricaFocus Bulletin today contains excerpts from reports on progress on AIDS treatment in Botswana and new doubts about political will to implement treatment plans in South Africa.

Many thanks to those of you who have already sent in your voluntary subscription payment to support AfricaFocus Bulletin. If you have not yet made such a payment and would like to do so, please visit http://www.africafocus.org/support.php for details.

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Keynote Lecture by Stephen Lewis at the 11th Conference on Retroviruses and Opportunistic Infections

United Nations (New York)

February 8, 2004

San Francisco, CA

...

What I want to try to do in these remarks is to flag the signals of hope as we enter 2004, and to look at some other related issues as well. The items are six in number; I shall deal with some elaborately, and others more briefly.

[WHO]

First, the single most dramatic development that has happened in years around HIV/AIDS is the decision, by the World Health Organization, in conjunction with UNAIDS, to achieve the goal of three million people in treatment by the year 2005: '3 by 5' as it's colloquially known. It has the potential to revolutionize the struggle against the pandemic. ...

I'm not going to go into detail of '3 by 5' there are handbooks and monographs available - but it is worth emphasizing that WHO sees the entire initiative as "the antiretroviral treatment gap emergency" ...

On the continent of Africa, it is estimated that 4.1 million people need treatment now - ie, their CD4 counts are below 200 - and approximately 70,000 to 100,000 are actually in treatment, or roughly two per cent. Quite frankly, that's an abomination. The total number of people worldwide who should be in treatment measures six million. In other words, even if the target of 3 by 5 is reached, some three million people - fifty per cent of those eligible - will continue to be in desperate straits come 2005, with the numbers growing daily. ...

That's why the WHO initiative is of such enormous import. It has unleashed huge expectations, great hope, and it's based on the recognition that prevention is profoundly strengthened when treatment takes hold. It cannot be allowed to fail. ...

There is, to be sure, a certain other-worldly, Ionesco quality to all of this. We have all the will and money in the world to fight the war against terrorism; what happened to the will and the money to fight the war against AIDS? Why conflict and not compassion? We're over twenty million dead, and counting.

With that in mind, there are four issues related to 3 by 5 which I'd like to address.

1.The World Health Organization needs up to $200 million, centrally, over and above its existing budget, to implement 3 by 5.

They need it for 2004 and 2005. They need it now. They need to train 100,000 people at country level; they need to hire teams of experts and dispatch them to the field, they need to put the whole elaborate logistical mechanism of drugs, capacity and infrastructure in place; they need to be the technical assistance providers of first resort. They will not succeed without the money. They don't have it. And though they have tried, they can't seem to get it.

Frankly, I don't really care where the money comes from; it just must come. The obvious and appropriate source would be individual donor governments. There's just no way around it: rich countries should provide the funds, and frankly, $200 million is a laughable pittance when compared to what the world spends its money on these days. ...

2. What clearly makes the best sense, if 3 by 5 is to succeed, is the WHO pre-qualified triple fixed-dose combination; one pill taken twice a day, available only from generic manufacturers. It's noteworthy that Medecins Sans Frontieres uses this drug with several thousand clients, in twenty countries, with excellent therapeutic results and excellent adherence rates. In order for us to find the money to put huge numbers of people into treatment, and scale up dramatically, this is the drug regimen of first-line choice. ...

Fundamentally, evaluations carried out by the WHO pre-qualification team provide assurance that international quality standards obtain. One of the great strengths of multilateralism is that we have the World Health Organization to do this work. There may be individual countries who wish to pursue a different tack. But when WHO has identified and pre-qualified generic drugs, at low cost, to prolong millions of lives, that's the route the international community, without caveats, should follow. ...

3. If there's one thing we've learned about testing and treatment, it's that the involvement of the community is decisive. If 3 by 5 is to make the intended impact, it must call on the community for help, and jettison the lip-service to which so many are addicted. And the key element of the community are the People Living With HIV/AIDS, who are the real experts, and must be acknowledged as such. They should be consulted on every aspect of the treatment process, and they should be seen as helping to mobilize the community to work, in an equal partnership, with the medical facility dispensing the treatment. Wherever this formula has been genuinely applied, testing increases exponentially, stigma and discrimination drop significantly, and adherence rates are generally higher --- I repeat, higher ---than they are in this city of San Francisco.

4. Finally, you can't achieve equity in 3 by 5 without opening the doors to women. I'll have more to say about that shortly, but at this stage let me simply point out that the disproportionate numbers of women infected in Africa, requires a similarly disproportionate access to treatment. ....

[Global Fund]

... Any discussion of treatment necessarily focuses, in large measure, on funding, and funding inevitably leads to the Global Fund on AIDS, Tuberculosis and Malaria. ...

It's time for the world to embrace the Fund, without all the
carping to which it has been --- often mindlessly --- subject. No
one pretends the Fund is perfect, including its own Secretariat.
But it is emerging as one of the most inspired multilateral
financial instruments that the world has latterly fashioned. And I,

for one, am nonplussed by the refusal to fund the Fund at levels which would save and prolong millions of lives. ...

This isn't some blanket apologia. I myself have occasionally been critical of the Global Fund and have raised with them some of the frustrations felt by recipient countries. But let's keep perspective here. In barely more than two years, we have an entirely new international construct up and running, admirably serving the interests for which it was intended, and getting money to the grass-roots of AIDS-plagued countries where it is so desperately needed. ...

You might think that the industrial nations would compensate for a decade of financial abstinence by embracing the Global Fund as the obvious vehicle for resource-constrained countries. But that hasn't been the case. At this moment in time, the Fund is several hundred million dollars short for this year, and almost three billion short for next. Nor are the omens auspicious. The administration of the United States has asked for only $200 million for the Fund for 2005, some $350 million less than 2004, and a billion short of what many active observers feel would be an equitable contribution.

The rule of thumb, based on gross world product, is one-third from the United States, one-third from Europe and one-third from everyone else --- everyone else comprising vast powers like Japan to sweetly diminutive states like Canada. In 2005, the Fund will need a minimum of $3.6 billion - hence $1.2 billion from the United States. This is not higher calculus: the arithmetic is clear. ...

... it must be said that no country, my own included, is paying an adequate share based on any reasonable formula. And that, quite simply, is shocking. ...

[Microbicides]

Third, this constant struggle for funding bedevils everything, including the critical quest for a microbicide. ...

Women must somehow be given control over a way to protect themselves from HIV, and that way is microbicides.

As more and more research is done on the particular vulnerability of women to infection, we're learning more about the situations in which risk is paramount. And extraordinarily enough, according to UNAIDS, the risk is particularly high in apparently monogamous marriages and partnerships. Ironically, and lethally, in the age of AIDS in Africa, marriage can be dangerous to women's health.

In the situation of intimate partners, condom use is very low. Nor can it be demanded. In representative surveys of women in 14 African countries, it was found that only 7% reported condom use in the last sex act with their regular partner. The prevailing assumption is that commercial or casual sex is the primary way in which women are infected. The assumption is wrong. There is a growing body of evidence to show that a significant number of infected women in Africa have been infected by their husbands or intimate partners. There is virtually no defence against that reality: the power imbalance in marriage is too great to permit or to request the regular use of condoms.

Thus it is that the classic 'ABC' intervention doesn't work in the one place where the risk for the woman may be greatest. Marriage without sex is not realistic, nor is it desirable. Abstinence in marriage is not possible; Being faithful is assumed; Condom use is irregular at best.

A way must be found to allow the woman to protect herself, independent of male hegemony. Female condoms are one possibility, but they are very expensive, and they require partner consent. And of course they act as barriers to conception. The most exciting prospect that we have on the scientific and social horizon is a microbicide. ...

Alas, we're still at least five years away from a first-generation microbicide. But with government support and financing, there are enough products in the testing pipeline now to achieve the breakthrough in that timespan. ... the shortfall is in the vicinity of $400 million. It may be higher. In May of 2003, the Global HIV Prevention Working Group recommended an additional $1 billion of public sector spending. But whether it's three-quarters of a billion, or a billion, it's peanuts in the vast panorama of international financial architecture. ...

The amount is so relatively modest - all the amounts related to HIV and tuberculosis and malaria are relatively modest in the grand scheme of things - that you have to ask yourself what kind of warped dementia has crept into the political process of assessing human priorities. Were we to pull out all the stops, and get microbicides of various types, and various levels of protection, to the market, we could give a significant measure of sexual autonomy to the women of Africa and prevent millions of HIV infections, and the millions of premature deaths that follow, and the millions of orphans left behind.

Can anyone in this illustrious gathering explain to me why that shouldn't be one of the greatest of political priorities?

[Vaccines]

Which brings me logically to the fourth item: is not the same true for a vaccine? It's interesting to me how the search for an AIDS vaccine is also struggling around issues of funding, and is often eclipsed, in public debate, by the preoccupations of care and prevention and treatment. ... just because a vaccine is a long-term proposition, and obviously very tough science, it cannot, it must not be depreciated.

These various aspects of the pandemic are not mutually exclusive. There will be limitations to vaccines as there will be limitations to microbicides, but a vaccine, as the ultimate answer to the catastrophe, must be pursued with an almost supernatural fervour. There should not be the slightest equivocation around funding. The rule of thumb suggests that roughly ten per cent of the resources allocated in the battle against AIDS should go to vaccines and microbicides. That's not happening. ...

[Women]

... We're paying a dreadful and inconsolable price for the refusal of the international community, every member of the community without exception, to embrace gender equality. And in so many parts of the world, gender inequality and AIDS is a preordained equation of death. ,,,

My problem ... lies in the divide between the analysis and what's happening on the ground. I read the superb studies produced by Human Rights Watch, and I know that the gap between rhetoric and reality can be tolerated no longer. In the last two and a half years, traveling extensively on the African continent, I have seen virtually no improvement in the status of women. Virtually none. ... it's time, truly and resoundingly, to take off the gloves. It's time for the respected UN community, for example, on the ground in countries, to join with the indigenous allies and groups fighting for women's rights to demand the visceral changes that are needed. It's time to abandon the fawning diplomatic deference. It's time to swallow the insufferable jargon, like 'mainstreaming gender' which serves to cement inequality by pretending that a process somehow transforms the lives women lead. It's not working. In Africa, of the ten million people living with HIV/AIDS between the ages of 15 and 24, nearly two-thirds are women and girls. Please explain to me what is working.

The time has come to confront Cabinet Ministers openly, and demand that they promulgate or amend the laws on property rights and inheritance rights. It's time to put people in jail, for a good long chunk of life, for property-grabbing. If sexual violence leads to HIV and death, then it's time to use the entire apparatus of the state to enforce laws against rape; to stop putting the onus on the woman to fight off predatory male sexual behaviour, and move in on the oppressor with a vengeance. If male teachers molest young girls, make a spectacle of them. If early marriage is a death sentence, change the age of marriage and enforce it as though life depends on it, because life depends on it.

It's time, in other words, country by country, to make the struggle for gender equality the cause celebre of the land. Give no quarter. Call press conferences, demand audiences with the political and religious authorities, form coalitions, take a tactical lesson from the Treatment Action Campaign in South Africa, demonstrate, boycott, rail, risk the possibility of being declared persona non grata by government, and if it happens, on this issue, wear it as a badge of honour. And should it happen, the cause of women will have been advanced.

It's all too much

too much sickness, too much sadness, too much death. Women are the resilient force that sustains the continent, and they are being eviscerated by a virus. And the world, there and here, largely inert, is watching it happen. Shades of the genocide in Rwanda.

You see, if we can make real gains in 3 by 5, and leverage the money for the Global Fund, and raise the intensity of focus on microbicides and vaccines, and understand that the pandemic has a woman's face, then we can begin to break the back of this appalling scourge. No one has to feel defeated. We just have to feel resolved. Doubtless it will require superhuman intervention: so much the better. It requires that level of magnitude to energize the world.

[Orphans]

But even all of that said --- and if it came to pass, it would be incredibly exciting --- there remains one issue, growing inexorably, that is thus far intractable: the issue of orphans. ...

African communities are struggling valiantly to absorb the orphans as the families fragment and die, but given the levels of impoverishment, it's desperately, indescribably difficult.

And it's all becoming so strange. Now we have, pervasively, this phenomenon which AIDS has brought, of grandparents burying their children, and then living out their impoverished days looking after the orphan grandchildren. I was in Alexandra Township in Johannesburg in December, meeting with a large group of grandmothers heroically networking through their anguish: they had all lost almost all their children. It was a spirited if terribly mournful conversation. There was one grandmother who refused to speak until the end. And then, in a voice of wrenching and unendurable pain, she told us how she had lost all of her adult children, all five of her adult children, between the years 2001 and 2003. Five children in three years. She was left with four grandchildren, all of whom I later learned, are HIV positive. Two generations will disappear in an historical blink.

And where they don't disappear, these millions of orphans wander the landscape of Africa. These lonely youngsters are bewildered, angry, sad, frantically seeking nurture and affection, often hungry, homeless, significant numbers living with grandmothers or in child-headed households, countless numbers unable to go to school, a school being the single most valuable and supportive environment they could possibly have - unable to go to school because they can't afford the school fees or the uniforms or the books. And when you lose your parents, who then hands down the knowledge and values from generation to generation? The orphan crisis is a crisis without parallel.

Somewhere, somehow, someday, the world has to understand what AIDS hath wrought. The understanding is not yet in evidence. ...

There's a true and acrid irony in all of this. We forever call for behaviour change in Africa and so much of the rest of the developing world. It's a valid call, no question. And because nothing is more difficult to change than sexual behaviour, it comes in painfully slow increments. But what about our change in behaviour? It isn't sexual; it's financial, economic, technical, psycho-social. And it progresses in increments even more infinitesimal. How do we get away with it? What is it doing to our collective humanity to deny life to millions?. With the money and the will, we can bring the scourge of HIV/AIDS to an end, and everyone here, in the depths of his or her soul, knows it. ,,,

What in Heaven's name are we waiting for?

Africa: AIDS & Financial Abstinence

Page Editor: Ali B. Ali-Dinar, Ph.D.