Your daily Selection of IRIN Africa PlusNews reports, 6/10/2003

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U N I T E D N A T I O N S

Office for the Coordination of Humanitarian Affairs

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CONTENT:

1 - ETHIOPIA: Interview with AIDS economist Alan Whiteside

2 - SOUTH AFRICA: Optimism over possible ARV rollout

1 - ETHIOPIA: Interview with AIDS economist Alan Whiteside

ADDIS ABABA, 10 June (PLUSNEWS) - Professor Alan Whiteside is a leading

AIDS economist based in South Africa. During a visit to Ethiopia, he spelt

out the scale of the continent’s crisis, explained how the enormous number

of AIDS orphans could mean potential disaster, and called on African

leaders to start addressing the tragedy.

<b>QUESTION:</b> Why has the HIV/AIDS pandemic reached such levels in

Africa?

ANSWER: There is a particular set of circumstances that have made Africa

particularly vulnerable to this epidemic. The first is the history, which

is one of grotesque exploitation by various colonial powers. The second is

the lack of good public health systems, which have been hugely important

in sustaining high levels of sexually transmitted diseases that are very

important for the transmission. And the third lies around accountable

government. One of the realities of post-independent Africa is that only

in a few societies do we have governments that have been accountable and

governments that have led for the people. So these circumstances coming

together have created an environment in which HIV was able to spread very

rapidly.

<b>Q:</b> What is the scale of the crisis if we can put it into context?

A: It is worse than the plague. If we were to design a disease which would

be the most disruptive possible, it would be very much like AIDS or

alternatively an airborne virus like SARS. The reason it is worse than the

plague is because it is a slow- acting virus, which means people will be

infected for a long time before they fall ill and before they therefore

know they are infected, unless they go for voluntary counselling and

testing.

It also takes out people in the middle ages; young people who have had

their education, have started their families and started up their career

paths or are productive in the villages and homesteads. With regard to the

scale there are parts of Southern Africa where 35 percent of the adults

are infected.

<b>Q:</b> What is the impact of so many orphans?

A: The answer to that is, nobody knows. One of the sad things for me is

there are things we could do to look after them. We could look at the way

in which orphans were taken care of in post-war Europe. We could look at

the way the orphan catastrophe was taken care of in Cambodia. There is no

history like this, we are writing history as times passes, and I have come

to the conclusion that AIDS is a Darwinian event – it is going to change

the way our societies exist and operate in Africa.

<b>Q:</b> How will it change society?

A: I don’t know. I think there are two possibilities. One is the Mad Max

world of enclaves of people being treated, and out there the starving

masses that are prepared to take up arms and are living a subsistence

existence, hand to mouth, dying young and creating more orphans.

The more utopian version is where we come together and say " this is an

issue we have to deal with " , and we start saying " we have to care for each

other " , and start saying " I don’t mind paying a little more tax in order

to survive " . Perhaps the end result will be somewhere between the two, but

it will certainly be a different world from the one we live in now.

<b>Q:</b> Will the infection rate eventually plateau?

A: It has to plateau, and where it will plateau we don’t know. That is why

prevention remains so important. So far, we have been consistently wrong

and overly optimistic in terms of our estimations of what is going on in

the epidemic. But I would say the levels you get in Botswana and Swaziland

have got to be very near the peak, which is 35 percent of adults. There

are going to be parts of Africa where this simply won’t happen.

Senegal has it under control, Uganda has brought it right down, and there

are indications in some African countries it is not more than 10 percent.

Tanzania has been consistently below 10 percent.

<b>Q:</b> Do you think the political will by African governments is there

to tackle the virus?

A: I think the will is there in some countries and when you look at where

the epidemic has been controlled, it is in countries where there is the

political will to control it. Here we are talking about Senegal and

Uganda, which are the two African examples. It is happening, but it is

happening very late and that is the tragedy of Africa. I think we must

have the political leadership if we are going to respond to this epidemic.

<b>Q:</b> What would you want to see African leaders doing?

A: Well, the first thing is you have to talk about it, you have got to be

open and honest about it all the time. If you do that you are creating a

space in which the ordinary citizen can acknowledge its existence. You

have to put resources towards it. Here we really are talking about finding

domestic resources as well as international donor resources. There has to

be a commitment from the local budget. You must also work out ways of

putting AIDS into everything you do.

So if you have a Ministry of Defence activity they need to be thinking

AIDS. If you have got the Ministry of Agriculture – they need to be

thinking AIDS. It has got to be there as part of your mainstream

activities.

<b>Q:</b> Is there sufficient capacity to absorb the enormous levels of

funding?

A: Finance isn’t a constraint. This problem is a low-finance,

high-human-resource problem. One of the most effective ways of dealing

with the epidemic is to encourage people to go for voluntary counselling

and testing. That means you need hundreds and hundreds of voluntary

counsellors because they have to deal with people pretty much on an

individual basis.

<b>Q:</b> Is poverty a key ingredient in this crisis?

A: Poverty is not only pushing people into being infected because they are

less healthy and women are more likely to engage in commercial sex,

because of mobility; it is also stopping people from staying alive longer

and it will certainly stop people accessing anti-retroviral drugs.

<b>Q:</b> Are anti-retroviral drugs [ARVs] a solution?

A: For an individual who is infected and who has access to all the things

that will enable them to sustain life and take ARVs, then they are the

answer. In some settings they are being rolled out very successfully -

like the diamond mines in Botswana. They are part of the answer – we have

to be providing treatment for people - but only part.

<b>Q:</b> What else needs to be done?

A: If you were to take someone who is HIV-positive, then obviously first

prize is to prevent them being infected. But we have to be realistic and

recognise there are 30 million Africans plus who are infected. What can we

do to make them live as long as possible before they need any form of

treatment? What can we do to ensure they don’t progress to the point where

they have ARVs – in other words treating opportunistic infections and

providing prophylactic treatment? The third question is, what do we do to

keep them alive when they have fallen to the point where they do need

ARVs, and that is when you would start introducing them.

<b>Q:</b> Is there hope?

A: Of course there is, the hope we see in Uganda and Senegal – the hope of

preventing the epidemic we see in Senegal and the hope of turning it

around we see in Uganda and increasingly in countries like Zambia. I think

what we are learning is if you are going to deal with this epidemic, it

requires a new way of looking at development and at people. You need

development that is people-centred, which is equity-centred and which is

caring. And that unfortunately has been sadly lacking in the world.

<b>Q:</b> But development agencies will tell you their approach is

people-centred, equity-based and caring?

A: That is seeing development as being a function of development agencies.

I think it is a function of good governance supported by development

agencies. Development agencies are part of the problem thus far, not part

of the solution. What we have is a picture of development agencies going

into certain countries and telling people how to develop.

At the moment it may be people-caring, but 10 years ago the development

paradigm was inward industrialisation, and before that it was rural

development. Development isn’t about development agencies. They are to

facilitate and to provide resources. Development is about governments

saying we are actually going to take care of our people.

<b>Q:</b> And do you think governments have not said that?

A: For the first 10 years of the epidemic the people who were most

concerned about it were donor agencies, which meant that the disease was

seen as a problem by the west – Africa did not see it as a problem. I

think that has changed very much in the last few years because we are

burying people.

<b>Q:</b> What do you see as the next step and are we moving in the right

direction?

Part of the problem is people like me. I am very vocal, I talk a lot but I

am a middle-aged white male academic. The people who need to be vocalising

about this should be more people from Africa, women, and they have got to

speak to their audiences. We do need to see a broader range of people

talking about this.

[ENDS]

2 - SOUTH AFRICA: Optimism over possible ARV rollout

CAPE TOWN, 10 June (PLUSNEWS) - 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.

[ENDS]

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