PI Action alerts & updates ... 2006

What’s Missing is Political Will

August 25, 2006, by Laurie Garrett, Toronto Star

“The means are available to fight the pandemic but the international AIDS bureaucracy refuses to recognize that AIDS is essentially a crisis of governance.”

The International AIDS Conference is over. The red ribbon pins, condom packs and HIV pamphlets that were littered about Toronto’s convention centre have been cleaned up, some 18,000 delegates and nearly 3,000 media representatives have headed home, and 5,000 convention volunteers have turned in their badges. Because he spent the week in Arctic climes, Prime Minister Stephen Harper escaped the sort of direct AIDS activists’ wrath that overwhelmed Brian Mulroney at the 1989 Montreal gathering.

And Toronto, having decided not to hang the sorts of solidarity banners and billboards all over the city that have typically welcomed delegates to past AIDS meetings, has avoided a big cleanup job. It’s all a rather nice, tidy package: over, done, forgotten. Thank you.

But in the global pandemic nothing is the least bit tidy, nice or done—thank you very much. It’s a bloody mess. Without giving it much collective thought, the AIDS campaign globally has walked right into the same traps that have plagued development and economic investment programs in poor countries for the last 60 years.

“We now have the means to reverse the global pandemic and to avert millions of needless deaths,” declared the United Nations General Assembly six weeks before the conference. According to the UNAIDS Programme, some 38.6 million people in the world today are infected with HIV, the virus that causes AIDS. More than 27 million have died of AIDS since the virus was first recognized 25 years ago. This year, about 3 million people will die of AIDS, and 4.1 million will be newly infected with HIV. We may have the means, as the UN said, to tackle these numbers, but it is not at all clear we have the political will.

American AIDS activist Gregg Gonsalves, who now works with the AIDS and Rights Alliance in South Africa, rightly denounced the “international AIDS bureaucracy,” which, he declared at the conference, has, “created a system designed to fail” because it refuses to recognize that “AIDS is essentially a crisis of governance, of what governments do and do not do for their people.”

In his plenary speech to the Toronto conference Mark Heywood, of South Africa’s Treatment Action Campaign, warned of the “price of political inaction.” Heywood cited former ANC leader Chris Hani, who told South Africans in 1990 that, “we are still at the beginning of the AIDS epidemic in our country. Unattended, however, this will result in untold damage and suffering by the end of the century.”

When Hani uttered that statement, Heywood noted, about 0.7 per cent of South Africa’s population was infected with HIV. In the 16 years hence, the prevalence of HIV in that country has soared to encompass more than a third of the adult South African population. In 1997, roughly 18,000 South Africans in their early 30s died prematurely; in 2004 the death toll in that age group skyrocketed to nearly 60,000 a year, indicating that “something” was claiming the lives of 42,000 men and women aged 30 to 34 years.

But six months ago President Thabo Mbeki said, “No one has sounded the alarm where I work in the presidency and nobody has said there is a particularly alarming tendency of people dying.”

South Africa is an extreme case, admittedly, but what political message did Harper send to Canadians by refusing to welcome the conference?

The political inaction Heywood spoke of can take many forms, and the lack of governance that galls Gonsalves encompasses not only the elected leadership of nations, but the UN agencies, major humanitarian and faith-based relief organizations, a seemingly infinite number of NGOs, the donor community and AIDS activists. All of these players should stop thinking in terms of cottage industry approaches to prevention and care of HIV, broadening their horizons to embrace global-scale systems of health, which nest HIV within a far larger agenda that aims to close the massive life expectancy gap between the rich and poor worlds.

UNAIDS Programme head Dr. Peter Piot warned the conference that the time had come to abandon crisis mentality, building a genuinely sustainable effort. Piot predicted HIV will still represent a clear and present danger to humanity 25 years from now.

“We must normalize AIDS, so that it is thought of and handled as just another disease, with no stigma,” Piot said. But normalizing treatment of HIV ought not to obviate the “need to maintain the exceptionality of AIDS in politics and public policy ... The end of AIDS exceptionality would spell the end of protected funding for antiretroviral therapy,” Piot insisted.

The Global Fund to Fight AIDS, Tuberculosis and Malaria is short $500 million just to meet its current commitments. Let’s be clear: We do need much more money to battle this pandemic. But money isn’t enough; it must be carefully managed and properly used.

In its macroeconomic analysis, the United Nations Development Program noted that international spending on HIV/AIDS programs in poor countries doubled, between 2002 and 2004.

Over the coming 18 months, HIV-related spending in poor and middle income countries will need to jump from the 2006 spending of about $8.8 billion to $18 billion. For poor countries, this escalation means that AIDS could by the end of 2007 command up to 10 per cent of their gross domestic product — for just one disease. The hardest hit African nations have witnessed dramatic increases in external funds: over the years 2002-2004, externally derived funding for HIV/AIDS programs grew more than 200 per cent in Uganda, 700 per cent in Zambia, 950 per cent for Swaziland and a whopping 1,100 per cent in Lesotho.

Many economists warn that such rapid escalations of foreign money could cause “Dutch Disease,” a term used to describe a condition in which spending of externally derived funds on social goods so exceeds private sector and manufacturing investment that the country is unable to gain a position of economic stability and independence. Its foreign exchange rate soars, the prices of its exports rise and therefore sales drop, further entrenching the country in permanent poverty.

A more immediate concern is that raising salaries for health-care workers and managers directly involved in HIV programs will lead to cries for salary boosts in other public sectors, such as education and the civil service bureaucracy, spawning inflation.

There is good reason to be worried: Some external programs and foreign NGOs are paying administrators, physicians and nurses up to 100 times what they can earn staying in their old health ministry jobs, and that is driving general demand for higher wages within government. If not carefully managed, the influx of cash could spark inflation, exacerbate malnutrition and homelessness in poor countries, and undermine any possibility that local industries could one day grow to be internationally competitive.

Even if Dutch Disease and the inflation threat sound like so much economic mumbo-jumbo, there remain serious problems regarding local control (the “Moral Hazard” argument) and health-care skewing. At the Toronto conference, some groups asserted that foreign donors — particularly the U.S. government — already exert too much control over the design and priorities of local AIDS programs. In some countries it now seems as if the foreign NGOs are running the show. Recently, for example, the Kenyan ministry of health gave up on attempts to compile a list of all the foreign-supported HIV organizations in that country, finding the list simply too large, and the NGOs resistant to government questions.

Political capital pulls hardest for HIV/AIDS. There are no anti-dysentery activists, and calls for child vaccination and maternal health programs cannot be heard amid the din of support for conquering AIDS.

Throughout the conference, African delegates decried a massive brain drain now underway, as meagre pools of health talent are dying of AIDS, getting recruited to work in rich countries, or simply shifting out of the public sector to higher-paying NGO and foreign-funded jobs. Fifty-seven countries now face critical shortages in health-care human resources, in a world with an overall deficit of 4.3 million, and growing.

Dr. Kevin De Cock, the new leader of the World Health Organization’s AIDS efforts, said that WHO failed to reach its goal of “3 by 5,” or getting 3 million people in poor countries on anti-HIV treatment by the end of 2005. The reason? De Cock said “the biggest obstacle to treatment scale up is the frailty of health systems.”

Erik Schouten, HIV co-ordinator for the Malawi health ministry, offered a heartbreaking rendition of what that frailty means. A nation of 12 million people, Malawi has lost 90,000 to AIDS and now has 930,000 people infected with the virus.

The country has 1.1 government physicians per 100,000 Malawians, and over the last five years has lost 53 per cent of its health administrators, 64 per cent of its nurses and 85 per cent of its physicians, with foreign NGOs being the major cause of this loss.

What of the health-care workers who once dealt with malaria in kids, vaccination programs, dysentery, maternal health and other issues?

Ibrahim Mohammed, who heads a similar effort in Kenya, said his nation lost 15 per cent of its health workforce between 1994 and 2001, but has only found donor support to rebuild human resource capacity for HIV/AIDS efforts.

Meanwhile, the wholly justified call for anti-HIV treatment in poor countries seems to have medicalized the epidemic.

Even the basics of public health—education and disease prevention—found proponents of medical solutions. And those “solutions” require further use of a beleaguered, exhausted pool of health-care workers.

For example, a recent study of the use of an anti-HIV drug called tenofovir prompted conference calls for a new form of prevention called PREP, or pre-exposure prophylaxis.

Tenofovir, which is usually used to treat people already infected with HIV, radically decreased the spread of viruses in a monkey study: the prophylactic-treated animals were 17.5 times less likely to become infected with the virus compared with their untreated counterparts. Based on that monkey study, many physicians advocate giving tenofovir or other anti-AIDS medicines to perfectly healthy, uninfected people, asking whether a pill a day can keep the HIV away.

Similarly, research shows that people who have the genital form of herpes are far more likely to become infected when they are exposed to HIV. And that has prompted clinicians to call for inclusion of acyclovir, an anti-herpes drug, in the package of HIV prevention.

What pool of doctors, pharmacists and nurses do these PREP and acyclovir proponents imagine will execute this medicalized prevention campaign?

For those who think that doling out such pills prophylactically need not entail medical expertise, Bluma Brenner presented lab work that shows tenofovir rapidly induces resistance mutations in HIV that affect a broad range of medicines.

How, in the absence of close medical management, can these drugs be used for widespread prophylaxis without promoting emergence of types of HIV that are more difficult, and costly, to treat?

The third new form of medicalized prevention, requiring use of more mythologically available health-care workers, is male circumcision. One South African study recently found that men who were circumcised had a 60 per cent lower likelihood of becoming infected with HIV.

Several large studies are now underway in Africa to determine the acceptability of adult circumcision in various cultural settings, and its impact on the spread of HIV, but data is not yet ready.

One cautionary presentation at the conference, however, compared circumcision, sexually transmitted disease rates, numbers of sexual partners and HIV rates in eight African countries, finding absolutely no statistically significant correlation between the presence or absence of a foreskin and men’s likelihood of acquiring HIV.

Kenya’s Kawango Agot drew loud cheers when she told the meeting that, “if it’s not helpful to women, it’s not helpful at all.” A conference study comparing 4,418 mates of circumcised vs. uncircumcised males in Uganda and Zimbabwe found, “no association between male circumcision and women’s risk of HIV.”

Billionaire philanthropist Bill Gates told an audience of 20,000 cheering conferees, “We need to put the power to prevent HIV in the hands of women.” Though Gates favours development of a vaginal microbicide as the female solution, such an innovation is still years away.

Several presentations at the conference suggested women may not be able to protect themselves against HIV, regardless of whether they have an effective microbicide on hand. One study of women in four African countries found that a quarter of all HIV positive women got infected through non-consensual sex—a polite way of saying rape.

More than a fifth of the women in the study said their first act of sex had been rape. Myra Taylor presented a survey of teenaged male attitudes toward women in a region of South Africa where 41 per cent of women are HIV positive. Ten per cent of the boys said “forced sex is okay,” and 36 per cent said, “It’s okay to hit her.” A separate South African study, conducted in KwaZulu-Natal, found “forced sex” the top predictor of female likelihood of having HIV.

It’s pretty tough for a rape victim to say, “Hold on a second while I get my microbicide.”

“Most women in Africa cannot make a decision about when, how or where they have sex,” Ugandan Beatrice Were, of ActionAIDS, said in a speech. “We cannot allow Africa to be blown away ... We need to speak up against rape and violence against women. Only the truth shall save us.”

We know what the truth of prevention is: condoms, sterile syringes in medical and drug-use settings, safe blood transfusions, and empowering women to have the right to say no to unwanted sexual advances. Yet Dr. Chris Beyrer of Johns Hopkins University showed that fewer than 2 per cent of intravenous drug users in Russia have access to sterile syringes, in a country where more than 95 per cent of HIV is acquired through shared needles among opiate injectors.

In medical settings the situation is only marginally better. A survey of medical clinics in Kenya, presented at the conference, found that 24 per cent of physicians, and 17 per cent of health-care personnel overall, had suffered a needle-stick injury over the last year—a high risk event in a country where more than 20 per cent of the patients are likely to be infected with HIV. The health-care workers, 93 per cent of whom said they were “very concerned about getting HIV on the job,” cited lack of essential medical equipment and training as the cause of frequent jabs with potentially contaminated sharps and needles.

Condoms? Well, another study estimated that the average African adult male has access to only six condoms a year, and in some hard-hit countries, condom availability has declined over the last three years. Improvements have been made in blood banks, but transfusions remain risky business throughout much of Asia, Africa and Latin America.

It’s too bad Harper and the two other heads of state invited to speak at the XVI International AIDS Conference shunned the gathering. They might have learned a thing or two.

In their absence, the new Queen of AIDS prevention, Melinda Gates, reigned, telling the crowd that, “It is hard to overstate the historic scale of our goal. In the history of human accomplishment, ending AIDS will fill a category all its own. It will stand as a work of scientific genius. It will be a testament to diplomatic brilliance ... it will be an accomplishment of the whole human family working together for one another.”