Critics+ignore+progress+on+AIDS,+Jeremiah+Norris,+Business+Day

Business Day, Johannesburg, 11 September 2006
=Critics ignore progress on AIDS=


 * Jeremiah Norris**

THE 60 international scientists who called this week for the resignation of Health Minister Manto Tshabalala-Msimang for her “inadequate” and even “lunatic” AIDS treatment programme ignore that SA is now one of the leaders in the developing world in providing antiretroviral (ARV) treatment. And all in the face of pressure from the United Nations (UN) to boost treatment as quickly as possible, in a way that would risk patient safety and increase drug resistance.

Tshabalala-Msimang has certainly made some odd statements about AIDS. But what matters now is how many people are getting ARV treatment in SA, and if that treatment is both sustainable and of a high quality. SA has one of the highest HIV prevalence rates in the world. But of the about 983000 patients in need, 140000 now receive ARV treatment, a figure that is rising all the time and is the highest in the developing world. This is remarkable progress.

In December 2003, the World Health Organisation (WHO) launched its “3 by 5” plan to put 3-million AIDS patients on ARV treatment by the end of 2005. Without consultation, it assigned a portion to SA, even though SA’s government already had its own plan. Worse, the WHO’s target for SA was hopelessly overambitious, representing more than were then being treated in the US, a country with one of the best health care systems in the world.

In July 2005, the WHO publicly admitted failure on “3 by 5”, partially blaming SA. Stephen Lewis, the UN ambassador for AIDS, recently accused SA of being “obtuse, dilatory and negligent about rolling out treatment”. But there are many worse performers. India now surpasses SA in numbers of infections. It has $598m in donor assistance. But the government of India has assigned a stingy $5m for 2005-2006. In the same period, SA’s government budget was $421m for roughly the same number of people with HIV/AIDS. Meanwhile, by the end of 2005 India was providing AIDS treatment to only 12000 eligible patients, while SA was providing treatment to 99000 (now around 140000).

In the total number of patients receiving ARV treatment, SA leads all of Africa and is ranked second only to Brazil, the 10th largest economy in the world.

In February 2004, President Thabo Mbeki told me his government would be criticised by WHO for its slow “rollout” of treatment but it was taking the responsible approach. This was in contrast to WHO’s plan, which recommended a rapid increase without adequate testing of patients, or proper infrastructure in place, and included the use of substandard ARV drugs. This risked both patient safety and increasing drug resistance.

I compared this to the fable of the tortoise and the hare. “Yes”, the president responded, adding, “You (donors) are here today, but we don’t know if you will be with us tomorrow.” That is why SA needs a sustainable programme.

There are currently two models for AIDS treatment. The WHO, impatient and hare-like, advocates treating as many patients as quickly as possible. The other can be characterised as a more clinical, tortoise-like approach, as in Brazil or SA. The first approach generates good PR but is extremely risky in poor countries with weak health infrastructure. The second approach is slower but, in time, it can speed up as medical personnel are trained, drugs properly certified, new laboratories and clinics open and as potential AIDS patients lose their fear of stigma by accepting treatment.

The WHO’s March report on “3 by 5” made no mention of any clinical details for the 1,3-million under ARV treatment. As a result, we do not know what their beginning CD4 cell counts were, what drugs were used, or if there were even patient medical records. The WHO clearly values numbers over patients.

The WHO and the UNAIDS ambassador for Africa are immune to the consequence of their recommendations. They are covered by the International Organisations Act and no lawsuit can be brought against them in any jurisdiction by patients who have had adverse reactions due to irresponsible “scale-up” of treatment. The leaders of poor countries, however, cannot similarly indemnify themselves.

In time, the tortoise will carry the day because it will have to live with the consequences of its recommendations over several generations. The hare, breezily free of any accountability, will soon go off to happily chase newer and more impossible global health goals without a glance backwards. The UN has to remember it is a membership organisation, and SA is one of its members. Instead of berating SA, the UN should learn from it.


 * Norris is director, centre for science in public policy, Hudson Institute, a policy think-tank in Washington DC.


 * From: http://www.businessday.co.za/articles/opinion.aspx?ID=BD4A269210**

789 words