|
by
Deborah Ewing
Of the 34.3 million people now estimated to be living with
AIDS1,
more than 70% live in sub-Saharan Africa. The reality of this is
that a person diagnosed HIV-positive today in the North is likely
to be prescribed comprehensive anti-retroviral treatment to retard
the progress of the virus and will receive immediate access to treatment
for opportunistic infections. A person diagnosed HIV-positive in
South Africa is likely to be prescribed a death sentence: “There
is nothing we can do for you. You must go home and prepare to die”
is the commonly quoted pronouncement of doctors informing patients
of their test results.
One delegate to the XIIIth International
AIDS Conference, in Durban, South Africa, said the face of AIDS
in his home country, Canada, was a billboard picture of health and
energy projected by the manufacturers of anti-retroviral drugs.
The face of AIDS in South Africa is the face of the baby born HIV
positive despite the existence of safe, effective treatments to
prevent mother to child transmission of the virus. It is the face
of the child who cares for his dying mother in a mud hut with an
outside toilet, water fetched from the river, wood collected for
fuel and only love for pain relief. It is the face of more than
200 000 orphans2,
who will bury their young parents this year. It is the face of the
15-year-old girl, who listens to her aunty, her teacher and her
priest telling her that ‘abstinence is the only cure for AIDS’,
who is forced to have unprotected sex by her boyfriend, and who
learns that she is now a statistic – the one in four 15-24
year-old South African girls and young women who are HIV positive.
For
a week, at the AIDS 2000 conference, these faces looked each other
in the eye and saw the gap between them, the reason for it, and
some hope for closing it.
South
African Constitutional Court Judge Edwin Cameron, a gay white man
on triple therapy, was one of the first to bridge the gap. Justice
Cameron disclosed his HIV status last year when a woman from a Durban
township, Gugu Dlamini, was stoned to death after disclosing she
was HIV-positive.
 Cameron
said as a person living with AIDS who could afford treatment: “I
embody the injustice of AIDS in Africa…I am living while others
have died simply because I can afford a combination of the anti-retroviral
drugs AZT, 3TC and Nevirapine.” He said it was monstrous that
he paid US$400 a month for this medication while 290 million other
Africans survived on less than US$1 a day: “I have many privileges
as a judge and I exercise them. I have the privilege to purchase
my life…Our overriding and immediate commitment must be to
find ways to bring to the poor what is within reach of the affluent.”
In
the months preceding the AIDS conference, the South African government
was widely judged to be in a state of denial bordering on paralysis.
The President of a country with officially the highest number of
HIV infections in the world – 4.2 million – was on a personal
crusade to rediscover the cause of AIDS. The controversy about Thabo
Mbeki’s stance raged through the conference and exasperated
delegates.
However,
in a programme that brought together scientists, doctors, researchers,
community health workers and treatment activists, the bigger issues
finally took over: what can be done to save lives; who is responsible
for doing it; and where is the money going to come from?
Dozens of presentations from all over the world, many from developing
countries, made clear that much can be done, and is already being
done, to prevent deaths, even in the most resource-poor settings.
National
government action, most notably in Uganda, Thailand and Brazil,
has successfully combined vigorous prevention programmes with efforts
to make affordable treatment available. Courageous and creative
non-government projects from Columbia to the Phillippines are bringing
care and hope to people living with AIDS.
There
are examples even from South Africa of combined prevention and treatment
initiatives having a significant impact. In Khayelitsha, one of
the most deprived townships in the country, the rate of mother-to-
child transmission of HIV has been reduced by provision of AZT to
HIV- positive pregnant mothers. Doctors managing this project believe
that with adequate training, this success can be replicated all
over the country within existing health services and infrastructure.
Eric
Goemaere, of Medecins Sans Frontières, said the Khayelitsha
project had had much wider impact than protecting babies from contracting
HIV: it was changing HIV/AIDS from an isolated, stigmatising experience
to a community priority; people were coming forward for testing
because they had hope of treatment. “Voluntary testing without
any possibility of getting treatment is nonsense.”
Access
to affordable treatment – especially to prevent mother-to-child
transmission – became the axis on which all debate turned.
That debate had three sides – the greed of pharmaceutical companies,
the inertia of national governments and the abdication of responsibility
by the international community. Locked outside of this debate were
thousands of poor communities carrying the burden of care for untreated
AIDS patients.
 Despite
much hype about slashed prices and dwindling profit margins, patents
enable pharmaceutical companies to keep the price of essential AIDS
drugs way beyond the reach of the world’s poor. Opportunistic
infections such as systemic thrush and cryptococcal meningitis,
are fatal in many people with AIDS. A course of fluconazole, which
is effective in treating them, costs about US$660 in South Africa
but can be imported from Thailand for about US$40. According to
the Treatment Action Campaign, drug company profits were US$27 billion
in 1999 – a year when three million people died of AIDS. The
argument about high research and development costs does not hold
since drugs, such as AZT, were researched with public funds. As
Peter Mugyenyi, a doctor from the Joint Clinical Research Centre,
Uganda, puts it: the world has upside-down drug access. “Drugs
are where disease is not and disease is where drugs are not. Commercial
interests come above human suffering.”
One
country that has turned this around is Brazil, where the government
issued a Presidential Decree making anti-retroviral and other AIDS
treatments available to all through the public health system. Pedro
Chequer of UNAIDS reported the massive savings of money and lives
through this programme over four years. Brazil can now treat 1000
people for the same amount it costs Uganda to treat 228 people.
This has been achieved by government importing and manufacturing
essential drugs at a fraction of the prices charged by pharmaceutical
giants.
Which
brings us to the second side of the debate: government inertia.
In the middle of the conference, the South African Ministry of Health
reasserted that prevention was the ‘core’ of its AIDS
policy, that reducing mother to child transmission had to be further
researched, that in a country with the highest rape rate in the
world, there could be no post-exposure prophylaxis for rape survivors
and that treatment for the millions who are already HIV-positive
was unaffordable.
Treatment
activists argue that affordability is a matter of priority: the
R6 billion (just under US$1 billion) a year the South African Health
Minister says it would cost at current prices to provide ARV to
all people with HIV is more than the total budget for all drugs.
However, it is less than a fifth of the SA government’s latest
commitment to buy armaments at R32 billion (US$5.3 billion) and
less than a sixth of the R40 billion (US$6.6 billion) spent every
year paying off apartheid debt. Instead of looking at the cost of
treatment, there needs to be a long hard look at the cost of not
providing treatment.
Developing
countries are losing productive people, including highly qualified
doctors, teachers, engineers – many of whom are caring parents
– every day. Sipho Zwane was the eldest of four children and
his parents sacrificed everything to secure him the education they
never had under apartheid. His brother and sisters were taken out
of school when money was short, and sent to work as a garden boy
and domestic servants to help Sipho get through university. He got
sick in his final year but he graduated in February 1999. Soon after,
his mother lost her job because she had taken so much time off to
look after her son. In April, Sipho died. This is not just a human
tragedy but part of a national economic catastrophe. UNAIDS Executive
Director Peter Piot told the conference that South Africa’s
GDP would fall by 17% by 2010 as a result of AIDS. “Economics
is now on the AIDS agenda but AIDS is not yet on the agenda of the
economists.”
Which
brings us to the third side of the debate: the international community.
‘Third World’ debt now stands at nearly US$370 billion3.
Macro-economist Jeffrey Sachs estimates that US$10 billion a year
is the minimum needed in donor support to Africa to mount an effective
campaign against HIV/AIDS, malaria and TB (the World Bank has just
offered $0.5 billion). To put that in perspective, Sachs says that
since 1996, the US has made US$6 trillion in capital gains on the
stock market. “So $10 billion in the US is not going to be
noticed… It’s about $10 per person in the rich countries…it’s
a movie ticket and a box of popcorn. It can be afforded.”
The
AIDS 2000 conference helped these three sides join hands in a circle,
in which a buck cannot be passed. As former president Nelson Mandela
said in closing the conference: “Now is the time to move from
rhetoric to action.”
Deborah Ewing is a development journalist and Assistant Editor
of the South African children’s rights journal ChildrenFIRST.
|
