ARVs - too little, too late

The long-awaited rollout of antiretroviral (ARV) drugs through public health systems is at last becoming a reality in a growing number of African countries. But the initial excitement greeting the announcement of each new AIDS treatment programme is often tempered by a closer examination of the figures, and the realisation that only a fraction of those in need will initially be able to access therapy.

In the case of Mozambique, the government aims to have just 8,000 people on ARVs by the end of 2004, out of an estimated 173,000 people eligible for treatment. By 2005 that target climbs to 21,000 out of 197,000 in need of ARVs – a shade over 10 percent.

"The fact that a country like Mozambique, with the leadership, the commitment, the partnership and support of the donors, will have just 21,000 on treatment in 2005 - that, to me, is shocking," said KY Amoako, head of the Economic Commission for Africa, at a three-day meeting of AIDS experts last week in Maputo, Mozambique. [www.uneca.org]

Amoako, chairman of the Commission on HIV/AIDS and Governance in Africa (CHGA), set up by UN Secretary-General Kofi Annan in 2003, led their latest gathering. The goal of the 20 commissioners is to analyse the impact of HIV/AIDS over two years, and promote effective policy responses among political, civil society and business leaders.

"What I've found really interesting is that even the most optimistic projections of treatment by governments are minute," said Alan Whiteside, a CHGA commissioner and University of KwaZulu-Natal professor. "If we talk about Mozambique, that by 2005 they will have 21,000 people on treatment, and you look at that in terms of WHO's [World Health Organisation] '3 by 5', I don't know where they are going to get three million [on treatment by 2005] from." [See separate interview: Interview with Professor Alan Whiteside, AIDS economist]

"I think the health systems cannot do more," he told PlusNews. "The answer isn't necessarily money - although that's crucial - it's to find ways of capacitating health systems to provide the treatment."

Fellow commissioner Milly Katana, an HIV-positive member of the board of the Global Fund, stressed a more activist role governments should play on a continent with the world's largest number of HIV-positive people.

"Our African governments have completely failed the people; they have failed to set the right priorities. Somebody said that in Africa we spend billions each year on weapons, but we cannot buy ARVs, which are now costing 50 US cents," she noted.

"The different priorities between us, as Africans, and donors also has a hand in it," she added. "We need large-scale programmes - we are no longer trying things at this point in time; we know what works; we know what doesn't work. When you talk about treatment, we know that generic drugs work - cheap and simple regimens - just give them to the people."

Whiteside said even for governments that were sincere in improving conditions of their people, difficult choices remained.

"I think African leaderships would love treatment to be there, but they are very well aware of their creaking health systems and the fact that, in Africa, you have to make choices between where you spend your money. Do you spend it on education or on health? And then, if you spend it on health, what do you spend it on - the disease that is killing most children, which is malaria - on immunisations which would provide long-term protection, or on antiretroviral therapy?"

An additional problem is Africa's powerlessness in negotiating agreements with pharmaceutical companies and donors.

In the 14-member Southern African Development Community there is no coordinated framework for an AIDS response, Mozambican health minister Francisco Songane told the meeting. There is no common approach to ARV treatment programmes in the region, whether in terms of deciding between generics or brand-name drugs, or the duration of funding secured from donors. He described the response of individual countries as "going with the opportunities that appear".

"I think we've heard very clearly in this commission a couple of comments on the funding that is coming," said Whiteside. "The first is that we don't know how sustainable it will be; secondly, that every source of funds comes with strings and reporting requirements, which are putting an additional burden on our resources in Africa."