Uganda will receive more than $90-million this year from the United States to assist it with preventing and treating Aids. Activists fear, however, that Washington may be showing too great a preference for abstinence-based programmes in its allocation of these funds — and that alternative prevention efforts such as condom distribution could suffer as a result.
Limitations on the purchase of generic anti-retrovirals have also prompted concern.
The money forms part of the President’s Emergency Plan for Aids Relief Funding (Pepfar), a five-year programme that aims to spend $9-billion on HIV/Aids prevention and treatment in 14 African and Caribbean countries. According to the Bush administration, these states account for 70% of the HIV-infected population in the two regions.
The plan was first proposed by US President George Bush in January 2003, but the first round of grants was not announced until February of this year. Uganda’s allotment is the largest of those given to the 14 countries targeted by Pepfar — even though its HIV infection rate is one of the lowest in Africa (according to Uganda’s Ministry of Health, the country at present has a 6% HIV prevalence rate — down from 20% in the early 1990s).
Some have pointed to the exclusion of severely HIV-afflicted countries such as Zimbabwe, Malawi and Swaziland as evidence that the choice of states was politically motivated. Relations between the US and Zimbabwe, for instance, have been frosty in recent years.
However, American officials say the selection was based on whether states had existing Aids programmes and infrastructure in place that could be expanded with an infusion of aid money.
While Pepfar does not restrict US funds to abstinence-based programmes, it does list prevention through abstinence and behavioural change for the youth as priority areas.
An official from the US Agency for International Development (USAid) said the Bush administration will allow Pepfar funds to be used to buy condoms, but that it prefers the prophylactics to be distributed among high-risk groups such as prostitutes rather than the general population.
A quote from a Pepfar report is telling in this regard.
“Evidence from Thailand suggests condom use is an important means of reducing, but not eliminating risk,” it notes. “Condom programs targeted to at-risk populations will be supported. In doing this, it will be important to disseminate clear messages that support rather than confound, a risk elimination approach.”
To date, $37-million has been disbursed to 20 organisations in the East African country (Pepfar will ultimately support more than 200 local and international groups through direct and indirect grants).
About a third of this funding appears to be targeted towards programmes that have some sort of prevention component, with $10-million going to the Aids Integrated Model District Programme. This grouping will distribute condoms to 260 000 people and carry out other prevention efforts to reach an additional two million. Uganda has a population of 25-million people.
But, a number of groups argue that the emphasis on abstinence is unrealistic in an African context, where the financial dependence of women may place them in situations that make it difficult to refuse sex. Young girls in Uganda are known to begin relationships with older men in order to get money for school fees.
“Many women don’t know their rights in Africa. Very few women can say no to a man, especially when you come to poor communities like ours here. One hundred percent of the women depend on men for survival,” says Francis Mbaziira, executive director of Kamwokya Christian Caring Community (KCCC), a faith-based group that is receiving Pepfar money indirectly through a grant given to the US-based Catholic Relief Services.
“So if the husband dies of Aids and the woman is left with four or five children, this woman is likely to go with any man if the children are to survive,” he adds.
Based in the slum community of Kamwokya in the Ugandan capital, Kampala, KCCC runs micro-credit programmes for widows to enable to them to become more economically self-sufficient — as well as a clinic and foster home for Aids orphans, among other activities. Thanks to Pepfar funding, the group will begin providing free anti-retrovirals for up to 500 people from next month.
Nonetheless, as a Catholic organisation KCCC does not provide condoms in its prevention and counselling programmes — or at the clinic, which caters for about 4 000 people. Mbaziira says that his group will tell people where they can get condoms if asked, but that KCCC does not see condoms as the answer to stemming HIV. Instead, it focuses on abstinence and fidelity.
“We are not here to stop people from using condoms but we are here to tell people the truth and let them make their own appropriate decisions,” Mbaziira says.
He admits it is an uphill battle.
“Abstinence, it’s hard. We’re trying all avenues. There are those who cannot abstain. So we cannot speak to one strategy; let us explore all the strategies that are there.”
At present, free condoms are distributed by several country-wide Aids prevention entities such as the Aids Service Organisation. In stores, a pack of three Lifeguard condoms costs about $25. Approximately 36% of Ugandans live on less than $1 a day, according to the Ugandan government.
Ironically, condoms formed a key part of Uganda’s drive to curb the spread of HIV during the past decade — this in terms of the “ABC prevention programme” that emphasised abstinence, being faithful and the use of condoms.
The US-based NGO Health GAP is concerned about the reluctance of the KCCC and like-minded institutions to give out condoms — even to men who are HIV-positive.
Spokesperson Brook Baker says: “He [Bush] is seeking to send an expanded corps of faith-based organisations to do work on the ground in Africa and is encouraging them to question condoms, condemn abortions and preach abstinence-only messages.” (Not all faith-based groups reject the use of condoms.)
A 2003 report by the New York-based Human Rights Watch, Just Die Quietly, points out that widespread marital rape and domestic violence are contributing to the spread of HIV in Uganda — putting something of a question mark over fidelity as a sure route to health for women. Married women are now seen as one of the groups with the highest risk of contracting Aids.
Although Pepfar acknowledges the link between violence against women and HIV, and pledges to support groups that protect women against sexual violence, none of the organisations in the first round of Pepfar grants for Uganda addresses this issue.
In addition, certain Aids groups and governments in the 14 Pepfar countries have complained about limitations on the purchase of generic anti-retroviral drugs with US money.
According to programme regulations, the funds may only be used to purchase drugs that have already been approved by a stringent regulatory authority, such as the US Food and Drug Administration (FDA) or one of its European counterparts. This effectively rules out generics, the USAid official said, as the makers of these drugs have not obtained approval for their products from these agencies.
On May 16, US Health and Human Services Secretary Tommy Thompson announced plans for a new FDA fast-track review programme meant to facilitate the approval of lower-cost anti-retrovirals.
However, the USAid representative said this initiative was really intended to speed up the approval of so-called “combination drugs” that include several treatments in fixed-dose pills. While these pills are less expensive than current treatments, they will necessarily consist of FDA-approved drugs — once again excluding generic medicines.
Citing concerns about quality, the USAid official said generics not approved by the FDA are being ruled out on safety grounds. The World Health Organisation (WHO) has given the green light to a number of generic drugs; however, the USAid official said the Pepfar regulations do not consider the WHO a regulatory authority.
Health GAP’s Baker is sceptical of these arguments.
“Instead of spending scarce resources wisely, the Bush administration is creating a slush fund for proprietary drug companies by its wilful refusal to procure dramatically cheaper and easier to use generic drugs.”
He adds: “Instead of treating four patients with the cheapest drugs of assured quality, Bush is settling for treating one patient based on exaggerated and misleading statements about the proven superiority of brand-name drugs.”
According to the Uganda Aids Control Project, only about 17 000 Ugandans are believed to be on anti-retroviral treatment in early 2004. A monthly supply of generic anti-retrovirals currently costs between $25 and $60, while brand-name drugs retail for between $86 and $560.
The USAid official said that the Bush plan aims to have 60 000 Ugandans on free anti-retroviral treatment by the end of the five-year programme.
Cissy Kityo, deputy director of the Joint Clinical Research Centre, a non-governmental research institute based in Kampala that has offered anti-retroviral treatment in Uganda since 1992, regrets the difficulties that surround the use of Pepfar funds to buy generic anti-retrovirals.
But, she makes it clear that any funds for fighting Aids are welcome in Uganda — including the $8,6-million that her centre will receive over the next three years.
“It is an exciting time for us, because even before the Bush initiative we were really trying to expand access to anti-retroviral drugs outside of Kampala,” says Kityo. “However, we moved slowly because we really had limited funds. Now with the grant that we have from the Bush initiative we are able to open new centres very quickly. Since the beginning of this year we’ve opened about seven centres.”
The organisation already provides about 12 500 Ugandans, mostly in Kampala, with generic anti-retrovirals at cost.
In addition to its core funding of $9-billion, Pepfar also plans to spend an additional $5-billion on existing bilateral Aids programmes in more than 100 countries.
The plan’s stated goal for the next five years is to put two million people on anti-retrovirals, provide care for 10-million HIV-infected individuals and Aids orphans, and to prevent seven million new infections. — IPS