Global Health Nexus

World AIDS Day

"Something is not working. Ten misconceptions impede prevention.".

On this day, I think I will defer to the latest Lancet editorial

Ten myths and one truth about generalised HIV epidemics by James D. Shelton:

And the "one truth":

Truthfully, our priority must be on the key driver of generalised epidemics—concurrent partnerships. Although many people sense that multiple partners are risky, they do not realise the particular risk of concurrent partnerships. Indeed, technical appreciation of their role is recent.6 But partner limitation has also been neglected because of the culture wars between advocates of condoms and advocates of abstinence, because it smacks of moralising, because mass behavioural change is alien to most medical professionals, and because of the competing priorities of HIV programmes.

Fortunately we can enhance partner-limitation behaviour, akin to the behaviour change that many people have adopted spontaneously. State-of-the-art behaviour-change techniques, including explicit messages, that are sensitive to local cultures, can raise perception of personalised risk. Even modest reductions in concurrent partnerships could substantially dampen the epidemic dynamic. Other prevention approaches also have merit, but they can be much more effective in conjunction with partner-limitation. Now, more than 20 years into HIV prevention, we have to get it right.

And on this theme, one could read William Easterly's review of The Invisible Cure: Africa, the West and the Fight Against AIDS by Helen Epstein:

One of the classic works of journalism of the last couple of decades was Randy Shilts's And the Band Played On[1] about the sluggish response to AIDS in the 1980s in the United States, which indicted both the Reagan administration and the leaders of the gay community. I still remember the sense of outrage I felt when reading Shilts's book; it struck just the right note, leaving one both horrified about the tragic incompetence of so many and yet also hopeful that someone, somewhere could do things better next time.

Yet after reading Helen Epstein's masterful new book, the response to AIDS in America now looks in retrospect like a model of courage, speed, and efficiency by comparison with the response in Africa. In the US, the government publicized the threat and funded research, the gay community reduced its infection rates by encouraging less risky sexual behavior, the dreaded breakout into the heterosexual population never happened, and AIDS receded to become a disease that, while still tragic, could in most cases be kept under control with expensive new antiretroviral drugs (ARVs).

The opposite is true in every respect of AIDS in Africa, which was anticipated as a looming crisis already in the 1980s, yet governments, foreign aid agencies, and even activists reacted with denials and evasion. The disease rampaged through the heterosexual population and is still rampaging, ARVs were too late, too costly, and available to too few, and Africa is still in the midst of an epic disaster without a solution in sight. As of the latest figures in 2006, 25 million Africans are HIV-positive, 2.1 million die from AIDS every year, and 2.8 million are newly infected each year.[2]

Or better yet, buy and read the book yourself.

FURTHERMORE:

UNAIDS

Appending AIDS statistics

UNAIDS in its annual report for 2007 is 'appending' its global AIDS statistics.

From the NYT:

The agency, Unaids, will lower the number of people it believes are infected worldwide, to 33.2 million from the 39.5 million it estimated late last year.

The statistical changes reflect more accurate surveys, particularly in India and some populous African countries. Some epidemiologists have criticized for years the way estimates were made, and new surveys of thousands of households in several countries have borne them out.

In July, India’s estimated caseload was revised downward, to 2.5 million, from 5.7 million — a change that accounts for about half the drop in the new Unaids figures. Officials said then that India’s epidemic was not “generalized” — that is, it had not spread far from the original high-risk groups like brothel workers and clients, truckers, heroin users and gay men. Also, rates among prostitutes appeared to have fallen as condoms gained acceptance. Instead of being considered the world’s worst-hit country, India fell to third place behind South Africa and Nigeria.

Despite the revised estimates, the epidemic remains one of the great scourges of mankind. This week’s analysis predicts that 2.1 million people died of AIDS in the last year, and 2.5 million were newly infected — or about 6,800 every day.

Here's the UNAIDS press release: Download 071119_epi_pressrelease_en.pdf - which has this to say about the revisions:

"UNAIDS and WHO and the Reference Group on Estimates, Modelling and Projections have recently undertaken the most comprehensive review of their methodologies and monitoring systems since 2001. The epidemic estimates presented in this year's report reflect improvements in country date collection and analysis, as well as better understanding of the natural history and distribution of HIV infection. This informations is vital in helping countries understand their epidemics ad respond to them more effectively.".

Rwanda applies to WTO to make use of Canada's Access to Medicines Act

In a developing story, (and in accordance with our previous post on this subject) Rwanda has applied to the WTO to make use of Canada's Access to Medicines Regime. It is the first country to do so. It is the first country to apply to the WTO under the 'paragraph 6 system' of the TRIPS agreement of the WTO which was designed to allow for developing countries to be able to import generic drugs they cannot manufacture themselves.

The Toronto Star picked up the story in this article by their health reporter Tanya Talaga:

For three years, the federal legislation has been on the books, but red tape – primarily licensing agreements between pharamceutical companies and generic drug firms – has prevented one pill from leaving Canada.

Now there is hope for 21,000 AIDS patients living in Rwanda.

It came yesterday after pharmaceutical giant GlaxoSmithKline Inc. agreed to allow Toronto-based generic drug manufacturer Apotex Inc. to use two of its patented molecules, zidovudine and lamivudine, to produce a three-in-one AIDS drug for Rwanda. Boehringer Ingelheim agreed last month to allow Apotex to use its product, nevirapine, to make Apo-triAvir.

That clears the way for Apotex to begin production of 15.6 million tablets, enough to treat more than 21,000 people for one year.

It's a drop in the bucket in a country where 190,000 people are infected with the virus.

Critics argue flaws in the legislation have prevented the export of any drugs. In fact, the federal government reviewed the bill this spring but failed to produce a report before the House rose in June.

"What we've learned from this three-year, incredibly cumbersome process is that this law is not working well," said Joanne Csete, executive director of the Canadian HIV/AIDS Legal Network. "It's almost a miracle Rwanda may be getting any drugs under this law."

Rwanda asked for Canada's help last month by notifying the World Trade Organization it would like to purchase 260,000 packages of a triple combination AIDS medication. Under the legislation passed in 2004, a voluntary, not a compulsory, licence is granted to the generic firm to make the drugs.

Here is Canadian HIV/AIDS Legal Network press release.

And from the GlaxoSmithKline press release:

GSK gives consent under Canada’s Access to Medicines Regime for generic version of HIV/AIDS medicine for use in Rwanda Not for distribution to US Media

Issued – 8th August 2007, London, UK, Mississauga, ON - As part of its broad commitment to improving access to medicines, GlaxoSmithKline today announced it has given consent through Canada’s Access to Medicines Regime to enable a Canadian company (Apotex) to manufacture a generic fixed dose combination (FDC) antiretroviral (ARV), containing two molecules over which GSK has patent rights (zidovudine and lamivudine) for the treatment of HIV/AIDS in Rwanda.
Canada’s Access to Medicines Regime reflects the WTO “31f” agreement of August 2003 and enables the government to authorise the production of certain patented medicines for export. The legislation includes controls which are designed to ensure that these essential medicines reach the patients for whom they are intended and the authorisation to be granted will be subject to these controls. GSK has agreed to waive royalties on the basis that Apotex’s triple combination generic ARV will be supplied on a no profit basis.
Paul Lucas, President and CEO, GSK Canadasaid, “Tackling the AIDS crisis is one of the greatest challenges the world faces. GSK continues to play its part to tackle this crisis through research and development, not-for-profit pricing and ongoing investment in dedicated community programmes. Our decision to allow Apotex to manufacture an FDC containing two GSK molecules is part of this broad commitment. It also shows that Canada’s Access to Medicines Regime operates effectively to enable supply of medicines from Canadaas envisaged under the 31f Agreement.”
About GlaxoSmithKline
GlaxoSmithKline – one of the world’s leading research-based pharmaceutical and health-care companies – is committed to improving the quality of human life by enabling people to do more, feel better and live longer.
GSK has issued eight previously announced voluntary licences to produce generic versions of GSK’s patented HIV/AIDS medicines for patients across Sub-Saharan Africa. In 2006 alone, GSK supplied 86 million tablets of preferentially priced ARVs to developing countries, while over 120 million ARV generic tablets were supplied by companies licensed by GSK.

The story also ran on the kasiernetwork.org. As it did on allafrica.com as well.

But as the Star article makes clear: "But (Ellie) Betito (director of public and government affairs for Apotex) pointed out the drug firms can still change their minds at any time. And Stephen Lewis, former United Nations Special Envoy for HIV/AIDS in Africa, said Rwanda still has the option to buy from other sources. Still, he said it was a significant moment.

"Forgetting all the negotiations and shenanigans over the last few years, we can begin to save lives. That is what is crucial."

It was the U.S.-based Clinton Foundation that coached Rwanda to seek help from Canada under the Access to Medicines Regime. It said other African nations are expressing interest in getting cheaply priced medication.

"We got into this because we want to see countries have access to a product that countries were struggling to get at high quality and low price," said Ben Yarrow, spokesperson for the Clinton Foundation.

More countries are seeking triple combination AIDS medication like Apo-triAvir because the toxicity is lower than that linked with other combination drugs like stavudine, a leading first-line AIDS drug.

Rwandans have been hit hard by AIDS in the years following the 1994 genocide that left nearly one million dead. There are an estimated 210,000 AIDS orphans living in the small, central African nation according to the United Nations. It is one of the poorest countries in the world, and more than 80 per cent of its people live on less than $2 a day.

The Clinton Foundation works with the Global Fund to Fight AIDS, Tuberculosis and Malaria and Harvard University's renowned Dr. Paul Farmer in the area. Also involved are President Paul Kagame and his wife, Janet Kagame, and, pediatrician Dr. Agnes Binagwaho, who heads AIDS work in Rwanda.

The World Bank and the Sub-Saharan African AIDS crisis- 1

Dr. Chris Simms had an article, in the June 5, 2007 issue of the Canadian Medical Association Journal that is essentially an brief overview of the World Bank's response and policy development with regards to the sub-Saharan African HIV/AIDS crisis from its beginning to the present, in light of the Bank's own 'indpendant evaluations' of itself on this subject. A subject that, inspired by this article, we will definitely be taking a closer look at.

Simms writes:

Between the early 1980s and 2000 the prevalence rate of HIV infection in sub-Saharan Africa increased from less than 1% to 12%,1 as illustrated in the prevalence maps in Fig. 1. This represents an increase in the number of people living with HIV infection from less than 1 million to 22 million.1 During this period, neither African governments nor the international donor community sufficiently prioritized HIV/AIDS or allocated adequate resources to help prevent and control its spread. In sub-Saharan Africa, the total amount of official development assistance actually declined in the 1990s, to about $3 per HIV-infected person by 1999.3 By this time, the international donor community had begun to focus on the HIV/AIDS pandemic and in 2000 began to send billions of dollars to sub-Saharan Africa to tackle the crisis. These investments appear to have had a positive effect: between 2000 and December 2005, HIV prevalence rates among adults were reported to have decreased in more than two-thirds of the countries in sub-Saharan Africa, falling from a mean rate of 10% to 7.5%.1

Although not excusing African governments for their own responsibility, Simms points out that realistically, the World Bank had enormous influence in setting health policy in the region. Simms:

It typically contributed about 20% of the funds needed to cover public health expenditures, and sometimes up to 30%–80% in the poorest countries.5 The World Bank was the pivotal player in the international donor community in the 1990s. With a general mandate to reduce poverty and improve living standards, and a remit to promote access to essential services in the health sector, the World Bank exercised enormous fiscal and policy leverage over governments and the other members of the donor community. This influence was due to the fact that (a) the World Bank was sub-Saharan Africa's main development partner; (b) it was the lead donor in terms of finance and policy in Africa's health sector; (c) it often acted as the "umbrella funder," designing and implementing integrated health strategies to which other donors would contribute; (d) it attached "conditionalities" to loans that needed to be met by borrowing governments for the release of funds; and (e) it acted in concert with the International Monetary Fund, which also had great monetary and fiscal influence. Indeed, the World Bank frequently draws attention to its influence, citing its comparative advantage in dealing with governments through dialogue, analysis and lending. In its seminal document, Intensifying Action Against HIV/AIDS in Africa, it acknowledged its de facto leadership role and implied responsibilities, stating that "those who look back on this era will judge our institution in large measure by whether we recognized this wildfire that is raging across Africa for the development threat that it is, and did our utmost to put it out. They will be right to do so."6

So why the 'insitutional weakness in the nineties', and then why the change? Simms writes:

In reality, the World Bank in the 1990s was actually focused on health sector reform, not on HIV/AIDS. A review of key World Bank documents showed that it sought repeatedly and explicitly to deprioritize the HIV/AIDS crisis in favour of health sector reform.11 The review revealed that, in 1992, the World Bank had warned that, "an expanded role of the Bank in AIDS should not be allowed to overtake the critical agenda for strengthening health systems."12 The remarkable conclusion reached was that, as the decade progressed, increasingly "AIDS was even less strategically prominent in the Bank's health sector strategy."12 To make matters worse, extensive data show that these very reforms, however badly needed, were poorly planned and underfunded and frequently had the effect of reducing access to effective health care, including services aimed at the prevention and control of HIV/AIDS. For example, with the promotion of cost recovery, it became commonplace to charge users for key HIV-related services, including the diagnosis and treatment of sexually transmitted infections, blood transfusion schemes, voluntary counselling and testing, and antiretroviral therapy.4

A series of institutional weaknesses identified in a review of the World Bank's investing activities in the health sector in the 1990s13 suggests that an effective response to the HIV/ AIDS pandemic by the World Bank was an unlikely prospect from the outset. First, the World Bank operated as a bank and kept its core business processes and incentives "focused on lending money rather than achieving impact." Second, it had weak incentives and underdeveloped systems for monitoring and evaluation and therefore did not use its lending portfolio to systematically collect evidence on what works, what doesn't and why. Third, the World Bank failed to develop good dialogue and consultation with its partners and local stakeholders — often preferring to "go it alone." Fourth, it took a "one size fits all" approach to country's situations that was insufficiently grounded in empirical evidence or institutional analysis of the local context. Fifth, it seldom placed sufficient emphasis on addressing determinants of health that lie outside the medical care system. Any one of these weaknesses would have severely undercut the effectiveness of the World Bank's response to the HIV/AIDS crisis. Collectively, they suggest the unchecked proliferation of ill-conceived, blueprint responses over a prolonged period from an institution out of touch with events on the ground. For example, upon reviewing levels of official development assistance targeting HIV/AIDS (about $10 per HIV-infected person globally and $3 in sub-Saharan Africa), the World Bank in 1997 concluded that "these allocations are remarkably large relative to national spending on the same problem and probably in comparison with international spending on any other disease. Perhaps only the international campaign to eradicate smallpox in the 1970s benefited from such a large preponderance of donor funds."14

Key institutional weaknesses of the World Bank's investing activities in the health sector in the 1990s

• Bank-like operations focused on lending money rather than on achieving impact

• Weak incentives and underdeveloped systems for monitoring and evaluation

• Lack of development of good dialogue and consultation with partners and local stakeholders

• "One size fits all" approach to countries' situations that was insufficiently grounded in empirical evidence or institutional analysis of the local context

• Insufficient emphasis placed on addressing determinants of health that lie outside the medical care system

Source: Johnston and Stout.12

This is all fairly damning - no? I suppose, but the reality was that the Bank was basically just being the Bank, and the full significance and scale of the crisis had yet to filter up. AIDS was unknown. Its scale was unknown, for years. Its safe to say that perhaps other than the government of Uganda nobody was pursuing an adequate policy. The World Bank Operations Evaluation Department report that Simms cites -Committing to Results: Improving the Effectiveness of HIV/AIDS Assistance (An OED Evaluation of the World Bank's Assistance for HIV/AIDS Control) frames it somewhat more, historically. From the report's executive summary:

The first AIDS cases were reported in the United States in 1981. For several years thereafter, the international research community strived to un- derstand the cause and modes of transmission of the new disease. By 1985, it became evident that a serious HIV/AIDS epidemic of unknown magnitude was taking place in parts of Sub-Sa- haran Africa. At that point, the Bank had been lending directly for health projects for only about five years; it had limited expertise on health or AIDS and followed the lead of the World Health Organization (WHO). Two factors framing the re- sponse of the Bank and the international com- munity were, first, the great uncertainty and rapidly changing information about a totally new disease—its epidemiology, its spread, and how to fight it—and, second, the extraordinary stigma and denial of the disease. There have been two distinct phases to the Bank’s response to HIV/AIDS. During the first phase, from 1986 to 1997, the Bank’s response was constrained externally by low demand for HIV/AIDS assistance by developing countries. Internally, the Bank’s response was held back by the focus of the Bank’s health sector leadership on vital health system reforms, eclipsing the ur- gency of investing in preventing the rapidly spreading HIV epidemic. As late as 1997, the Bank’s health, nutrition, and population (HNP) strategy contained no discussion of the AIDS epidemic, mentioning it only in a remote part of an annex in the context of emerging diseases. Nevertheless, during this period about $500 million was committed in loans and credits to 8 free-standing projects and 17 significant compo- nents to support national AIDS programs on 4 con- tinents in countries at all stages of the epidemic. The initiative for AIDS strategies and lending came primarily from individual health staff in the regional and technical operational groupings of the Bank, but not in any coherent way from the Bank’s HNP leadership or top-level management. The Bank collaborated closely with the WHO Global Program on AIDS (GPA) in project design and in launching important analytic work on the cost-effectiveness of AIDS interventions. The second phase of the Bank’s response, from 1998 to the present, is one of high-level in- stitutional mobilization and advocacy in which the Bank began to take a proactive role in raising awareness and demand for AIDS support among its staff and client countries. Several significant de- velopments in 1996–97 may have contributed to this shift: the creation of the Joint United Nations Program on HIV/AIDS (UNAIDS), which took on a strong advocacy role and was capable of di- rectly reaching high-level Bank management; the issuance by the Bank of a major research report that highlighted AIDS as a development issue; and the development of highly active anti-retroviral therapy (HAART) in 1996. There was also in- creasing international evidence of the scope and impact of the epidemic. Since 1998, HIV/AIDS strategies or business plans have been completed in nearly all geo- graphic groupings of the Bank, and an addi- tional $2 billion has been committed to support national HIV/AIDS programs in 55 countries at all stages of the epidemic. Roughly half of the new commitments since 1998 have been through more than two dozen projects of the Africa MAP, and the balance to projects in South Asia, East- ern Europe, Latin America, and the Caribbean. The main objectives of these projects, as artic- ulated in design documents, have been to pre- vent the spread of HIV, provide treatment and care, mitigate the impacts of AIDS, build national institutions, and provide public goods.

I have not finished reading the full report yet, but I will, and as I said we will be pursuing this subject further.

Simms:

In fairness, bilateral and multilateral agencies were generally no more effective than the World Bank in their response to the HIV/AIDS pandemic. However, none of these agencies was in comparable positions of leadership or influence. Furthermore, none of this critique removes the onus from African governments to do more: Uganda and Senegal have shown what can be achieved when there is strong political will, just as South Africa has shown the consequences of its absence.