Belinda Beresford
December 1 is World Aids Day, when red ribbons will be sported worldwide, speeches and promises made and learned research released and debated.
Heart-rending stories of the dyingand those they leave behind, indignant news items about the high cost of drugs, and hand-wringing about the failure to change human behaviour push Aids to the foreground of the world’s attention.
The theme this year is “I care … Do you?” and has a special focus on male responsibility for the transmission of HIV. South Africans are being urged to “light a flame for life”. President Thabo Mbeki will be lighting a national flame in the North West province.
However, the litany of promises appears to be breached more often than observed and those promises that are fulfilled take a long time to come to fruition.
Take the case of Fluconozol, a drug used to to treat some of the conditions strongly associated with HIV/Aids: cryptococcal meningitis (a brain infection affecting about 15% of those with HIV) and oesophageal candidiasis (a form of thrush which can infect the whole gastrointestinal tract from the mouth to the anus).
A year ago Minister of Health Manto Tshabalala-Msimang stood beaming with representatives from pharmaceutical company Pfizer, which had agreed to donate the drug to the government on terms that pleased both parties.
The donation had originally been offered in early 2000, but only for those with brain infection, and only if the condition had been diagnosed through a lumbar puncture a procedure that requires a high level of medical expertise. Negotiations lasted almost nine months before the two sides came to an agreement on the terms of the donation.
It took another four months for the guidelines regarding the use of the drugs to be written, let alone distributed to hospitals and clinics around the country.
This year saw breakthroughs in the global campaign to reduce the cost of medicines in poor countries. The World Trade Organisation recognised the right of countries to override international patent rights in cases of health emergencies, although it’s certain that many years of wrangling lie ahead.
Drug companies cut prices and offered donations to poorer countries, especially for HIV-related drugs. Boehringer Ingelheim, for example, has offered free nevirapine. If one pill is given to a pregnant woman in labour, the chances of her child catching HIV are halved. Not one country is known to have taken up the offer.
Such offers are not all altruism; they allow the drug companies to protect their patents, and prevent precedent-setting moves such as the threat of compulsory licences.
The South African government had its moment of glory when it faced down a legal attempt by some of the world’s biggest pharmaceutical companies to curb legislation that would streamline government access to cheaper drugs not just anti-retrovirals. The court case between the Pharmaceutical Manufacturers Association and its members and the government ended with the association withdrawing and paying costs. But, publicly at least, there appears to have been little movement on getting the cheaper drugs.
The year has been dominated by complaints from activists and health-care workers that the South African government has been dragging its feet on confronting the epidemic. It has also been marred by the ongoing argument about what Mbeki has actually said, or not said, about the link between HIV and Aids, amid repeated warnings from the private sector that the controversies swirling about HIV and the government are damaging investor perception of the country.
The private sector itself has come in for both bouquets and brickbats. Debswana, the Botswanan diamond company, announced it would provide anti-retroviral therapy for each worker who needed it.
Anglo American first appeared to announce that it might do the same, then stated that it would content itself instead with pilot studies into the feasibility of such treatment.
Studies indicate that HIV prevalence in the private sector tend to mirror that in the surrounding communities and that the poorest and least skilled workers tend to have the greatest number of infections.
But it is the government that has come under most fire. At the beginning of this year the presidential Aids advisory panel delivered its interim report that to no one’s surprise neatly reflects the division between those panelists who believe in a causal link between HIV and Aids and those who doubt it to varying degrees. Research into some of the questions raised by the panel continues: such as testing the accuracy of laboratory tests for HIV which passed with flying colours.
The latest controversy came in October with an acrimonious fight about exactly how many people in South Africa have HIV. The Medical Research Council’s internationally audited report was slated by Statistics South Africa.
Epidemiologists acknowledge that no one knows exactly how many people are HIV-positive, but complain that the government’s refusal to release a detailed breakdown of the antenatal study hampers statistical analysis. Others point out that infection levels are catastrophic, whether more than the officially estimated 4,7-million or less than that number are carrying the virus.
Africa contains by far the greatest proportion of the people in the world living with HIV. Not coincidentally, it is also fraught with natural and man-made disasters.
Many African countries are crippled economically, either through war, neglect or corruption, and carry resource-sapping international debts. Poverty and the behaviour that tends to accompany it commercial sex work, violence, lack of nutrition, poor medical facilities, prevalence of infections including sexually transmitted diseases facilitate the spread of HIV.
Researchers and health-care workers in South Africa repeatedly say that for many people they encounter, the choice is between starving now or earning money through sex work and risking death in a few years’ time.
South Africa’s health service is in a dire state. The vast proportion of medical resources in the country is used by the private health industry that services less than 20% of the population. The legacy of apartheid includes rural areas with little, or effectively little, access to health care. There are woefully understaffed clinics with sporadic electricity and limited access to drugs.
Increasing legal challenges are being mounted against the government to facilitate access to medicines, especially anti-retroviral drugs that can hold the virus at bay for years, possibly decades. Activists such as the Treatment Action Campaign and international aid organisations such as Mdcins Sans Frontires say that concerns about toxicity of drugs and the risk of drug resistance are being used as an excuse not to provide anti-retrovirals in the public sector.
The government counters that it does not have the health infrastructure to provide anti-retrovirals safely and effectively. To do so requires physical infrastructure, such as laboratories, as well as knowledge few doctors actually know their way around the full intricacies of anti-retroviral therapy.
Closer to home, the Botswanan government announced that it would provide anti-retroviral drugs for everyone who needed them. Botswana, with about 1,5-million people, probably has the highest number of HIV infections per capita in the world, with an estimated third of the adult population carrying the virus.
Politics rather than science continues to inform state responses to HIV. In Mpumulanga MEC for Health Sibongile Manana threw the Greater Nelspruit Rape Intervention Project (Grip) out of the two hospitals where it was working after discovering that it was helping rape survivors get access to anti-retroviral drugs, thought to cut transmission of the virus from rapist to victim. Grip went to court. The saga is ongoing.
Manana questioned the safety of using anti-retrovirals as post- exposure prophylaxis for which they are used in many countries worldwide and allegedly said that black women were being used as guinea pigs.
Grip’s lawyers, the Aids Law Project, filed a complaint with the Human Rights Commission accusing Manana of hate speech. The Aids Law Project is made up of the lawyers for the Treatment Action Campaign, which this week sued the government for breach of its constitutional obligations by failing to make drugs available to HIV-positive women to cut mother-to-child transmission.
The Health Professions Council, the regulatory body for medical practitioners, has also come under fire. The Aids Law Project has filed a complaint with the Public Protector that the Health Professions Council has failed to protect patients’ rights to confidentiality regarding their HIV status.
Of the 28 cases lodged against doctors with the Health Professions Council over the past four years, not one has been found guilty although in three cases the complainants won civil claims.
Internationally the United Nations secretary general launched a Global Aids and Health Fund in April. Designed to pool resources to combat HIV, tuberculosis and malaria, the fund had a target of $15-billion by the middle of this December. So far donations are far below that especially after United States President George W Bush announced the US would give only $200-million to the fund.
Despite huge volumes of money being poured into Aids research, a cure still seems a long way away.