---------- Forwarded message ----------
Date: Mon, 10 Dec 2001 20:11:12 -0500
From: Africa Action <[log in to unmask]>
To: [log in to unmask]
Subject: Africa: AIDS Policy Updates, 2
Africa: AIDS Policy Updates, 2
Date distributed (ymd): 011210
Document reposted by APIC
Africa Policy Electronic Distribution List: an information
service provided by AFRICA ACTION (incorporating the Africa
Policy Information Center, The Africa Fund, and the American
Committee on Africa). Find more information for action for
Africa at http://www.africapolicy.org
+++++++++++++++++++++Document Profile+++++++++++++++++++++
Region: Continent-Wide
Issue Areas: +economy/development+ +health+
SUMMARY CONTENTS:
This posting contains the concluding statement from a meeting of
international experts held in Paris on care for people living with
HIV/AIDS. The statement clearly spells out the need for the Global
Health Fund for AIDS, TB, and Malaria to prioritize financing for
AIDS treatment, inclusive of antiretroviral drugs.
(The statement is slightly abridged for this e-mail posting. The
full text will be available in the on-line archive of this posting
at http://www.africapolicy.org/docs01/par0112.htm)
Another posting today has other recent documents related to funding
and priorities for the Global Fund.
+++++++++++++++++end profile++++++++++++++++++++++++++++++
MEETING ON ACCESS TO CARE FOR PEOPLE LIVING WITH HIV/AIDS 29th-30th
November & 1st December 2001
This international experts meeting was held in Paris at the
invitation of the French Ministry of Foreign Affairs, with the
support of UNAIDS Secretariat and WHO.
1 December 2001
Paris, France
DECLARATION FOR A FRAMEWORK FOR ACTION: IMPROVING ACCESS TO
HIV/AIDS CARE IN DEVELOPING COUNTRIES
I. Introduction and Purpose of the Document
With an estimated 40 million people infected with HIV worldwide and
26 million accumulated deaths, HIV now stands as the worst
infectious disease pandemic in recorded history. The threat imposed
by HIV is reflected not only in the tragedy of each individual case
and his/her affected loved ones but on the global scale of human
health and the potential for demographic, economic and political
destabilization in many countries. Access to HIV prevention and
care services have long been championed by international
organizations, governments, non-governmental organizations and
community groups. However, we are far short of providing
HIV-infected people worldwide with appropriate care. In the last
two years, an extraordinary juxtaposition of events has given us an
opportunity that must be seized. Since the International AIDS
Conference in Durban in July 2000 and the United Nations General
Assembly Special Session (UNGASS) in June 2001, the world is
mobilized as never before to address the issue of HIV/AIDS in
developing countries. The tools which can change the course of the
epidemic are in our grasp. The benefits of treatment in terms of
preventing illness and death from HIV infection have now been well
demonstrated. Access to HIV medications must now be ensured for the
millions of infected persons in the developing world within the
broader context of appropriate care, prevention and support.
Current resource allocations are woefully inadequate, substantially
less than 25% of the annual estimated need, to meet this goal.
Future generations will judge us harshly if we fail moving rapidly
toward the minimum 7-10 billion dollar per year allocation that was
called for in June 2001.
The purpose of this document is two-fold. The first is to set forth
a clear framework for improving and accelerating access to care for
HIV-infected women and men in the developing world. In particular,
the document proposes near-term goals that are achievable. Specific
priorities are outlined with a timeline of 18-36 months. The second
purpose is to serve as a start for mobilizing organizations and
people to an ongoing, progressive, sustainable action plan that
will help to make the UNGASS declaration become a reality.
This document is the product of a year long consultative process
involving 155 experts from 27 countries and 57 national and
international organizations. It is the consensus of the
participants who convened in Paris at the invitation of the French
Ministry of Foreign Affairs, UNAIDS and WHO on 29 November - 1
December 2001.
II. Current Status of HIV/AIDS Care in Developing Countries
(Including Achievements Thus Far)
A. Prevention, Care and Support (Emphasizing Synergy)
As already shown by successful local and community responses to
HIV/AIDS, prevention and treatment are synergistic : access to HIV
treatment enhances the effectiveness of prevention as well as
voluntary counselling and testing (VCT) programs. Prevention, or
the reduction of new infections in the seronegative population,
should not be pitted against care for those who are already
HIV-infected. The idea that prevention could be more effective than
treatment ignores their interdependence and indivisibility.
There is no disputing that targeted prevention strategies that take
into consideration poverty, discrimination, inadequate education
and gender inequality are effective in reducing HIV transmission.
However, they will not be able to curb the pandemic in the absence
of parallel efforts toward persons living with HIV. It is estimated
that 9 out of 10 HIV-infected persons in sub-Saharan Africa do not
know their serostatus. This is unlikely to change unless access to
adequate care in case of a positive test result is offered. In
addition, availability of effective care and treatment options
reduces HIV-AIDS related stigma and increases societal and local
responses to the epidemic.
B. Economic Opportunities and Constraints
Assuming that 20%-25% of the HIV-infected persons world-wide are
symptomatic and/or in an advanced stage of immunodeficiency, 7.5 to
9 million living in developing countries are in urgent need of
antiretroviral treatment (ARV). In contrast, a total of only about
200,000 HIV-infected persons, of whom 100,000 live in Brazil, use
these treatments. This is less than 3% of those in need. At current
discounted prices of antiretroviral drugs plus other costs of
treatment (1,200 US$ per patient per year for both) the
availability of 240 million US$ in 2002 would result only in a
doubling of the number of treated persons, a positive but only a
small step forward.
Clearly there is an urgent need for supplemental resources if
additional lives are to be saved. In order to reach at least a
third to one half of the 7.5 to 9 million people estimated to be in
immediate need of treatment, additional funding is required for the
Global Fund to Fight Against AIDS, TB and Malaria and from
international co-operation, the private sector and insurance, as
well as public budgets from national governments.
A number of national and smaller pilot programs in middle-income
(Argentina, Brazil, Chile, Thailand, etc.) and low-income (Cote
d'Ivoire, Senegal, Uganda, etc) countries have demonstrated a
comparable feasibility, efficacy and adherence with antiretroviral
treatment to those obtained in high-income countries.
The Brazilian experience, which ensures universal access and
enhances domestic drug production, shows that ARVs can be
cost-saving for the health care system : extra costs of drugs are
more than offset by further savings due to the reduced number of
episodes of opportunistic infections and consequently reductions in
hospitalization (according to the Brazilian Ministry of Health net
savings through ARV use amounts to more than 140 million US$ per
year). ...
Even if they do not save money per se, new health interventions are
considered as cost-effective in the North as soon as their marginal
cost per additional life-year saved is below twice the GDP per
capita (50,000US$ in OECD countries). Applying the same criterion
to developing countries with lower GDPs, means that antiretroviral
treatment should also be considered cost-effective for eligible
patients in low-resource settings. Moreover, human and social
benefits from increased life-expectancy and quality of life of
HIV-infected patients go far beyond their direct economic impact
for treated patients and include improved social and human
development for their families, communities and country as a whole.
III. Key Issues and Opportunities
The care of HIV infected persons is multidimensional and the
components must be clearly delineated. In this context, it is
important to re-emphasize that prevention of new infections and
care of those already infected are tightly linked and synergize
with one another. National AIDS programs and international agencies
have outlined many of these critical features and it is not the
point of this draft declaration to reformulate these documents.
Rather, it is to highlight the most critical areas which require
resources, at the country level, in order to scale up the most
effective programs for access to care.
1. Uniform availability of voluntary counselling and testing (VCT).
Where this does not exist, appropriate measures should be taken
immediately to scale up these programs. Proper assessment of an
individual's HIV status permits educational measures to help
negative persons remain negative and positive persons to enter into
care. The latter, in turn, facilitates prevention efforts through
interventions to prevent secondary transmission whether this be
behavioral modification or entry into mother-to-child transmission
prevention programs in the case of pregnant women. Increased
testing capacity will also contribute to ensure a safe blood
supply. A key element of strengthening VCT programs is the parallel
availability of antiretroviral drugs. The hope of accessing life
saving therapy will encourage more people to seek VCT services and
thereby directly assist the prevention efforts.
2. Scaling up of MTCT prevention programs. One of the greatest
achievements of the past decade is the demonstration that MTCT of
HIV can be dramatically reduced by antiretroviral drugs. In the
developed world the rate of infection of newborns is less than 2
percent and is near zero in women who receive proper antenatal
care. Attaining this degree of success in the developing world will
be difficult because of the absence of uniform access to antenatal
care and the need for breastfeeding. In spite of these
difficulties, reductions of MTCT by 50 percent have already been
demonstrated in the developing world through the use of nevirapine
or short-course zidovudine (AZT). These programs must be put in
place in every health care setting. ...
3. Opportunistic infection (OI) prophylaxis and treatment. The
proper management and prevention of opportunistic infections has
been proven to have a positive impact on morbidity. Uniform access
to drugs, such as antituberculous drugs and cotrimoxazole, is a
cost effective intervention that is a mandatory component of care.
Antiretroviral therapy is by itself the best prophylaxis for
opportunistic infections. Scaling up antiretroviral treatment will
progressively reduce the need for anti-OI drugs.
4. Improving access to antiretroviral therapy. The revolution in
care in the developed world is unquestionably linked to the
availability of powerful combinations of antiretroviral drugs.
Dramatic reductions in morbidity and mortality have been well
documented and this benefit needs to be made broadly available to
persons in the developing world. It should be re-emphasized that
antiretroviral therapy is already being used in the developing
world, although on a small scale in low-income countries, with the
demonstration that it is feasible and effective. Further, drug
adherence appears to be comparable to the developed world and the
concern for the spread of drug resistance is not a valid reason to
delay introduction of therapy anywhere. ... Conversely, failure to
expand treatment in a systematic way will certainly increase the
risk of non-rational prescription and use of antiretrovirals
ensuring a greater incidence of drug resistance. ...
Antiretroviral treatment programs need to be scaled up as rapidly
as possible simultaneously with provision of health care worker and
facilities capacity to permit and facilitate care delivery.
Programs which build on existing MTCT prevention (e.g., MTCT
"plus") and tuberculosis control programs are key entry points for
antiretroviral therapy programs. ...
5. Psychosocial Support. A key element of care for all HIV infected
persons is psychosocial support, including palliative care. The
high incidence of depression and other emotional illnesses should
be acknowledged in order for hope to be nurtured. Good quality care
requires sufficient numbers of properly trained health care
workers, traditional healers, religious and community leaders and
volunteers to help patients and their families to develop the best
ways of coping at all stages of HIV disease, and particularly with
end of life issues. Appropriate psycho-social support will more
than ever be needed to facilitate access and adherence to
treatment.
IV. Framework for Implementation of Priority Programs
A. Approach for Efficient Implementation
While a demand-driven, participatory, and progressively
decentralised approach will enable broadening of health care
services, a central capacity is also needed at national levels for
protecting people's rights, promoting price reductions for HIV/AIDS
drugs and services, quality control of drug and service delivery,
monitoring and evaluation.
In order to create systems for delivering care to significantly
more people, training of personnel will be critical. In addition to
supporting clinics, hospitals and homecare programs, countries need
to aggressively work toward transforming existing volunteer and
community-based organisations into AIDS service organizations.
Latent capacities to demand and provide for care and treatment are
widespread in families, communities, and organizations. ...
Once reference centres in large cities are functioning, these
centres should be used to train people working in smaller cities or
rural communities as is being done in Brazil, Cote d'Ivoire Senegal
and Uganda. One innovative model for providing care is
"Association-Based Treatment" (e.g., Burundi, Zimbabwe, Venezuela).
Within this model the financial and material treatment resources
are controlled and managed by the associations of people living
with HIV/AIDS, together with doctors and other providers. In this
context HIV infected women and men are directly involved in the
decision making process and organization of all aspects of HIV
care.
Without medicines, reagents for diagnostic testing and monitoring,
improved human resources will be compromised and ineffective.
Therefore, how to offer international support to augment local and
national procurement efforts will be critical. Since the
availability and sources of commodities will vary dramatically,
international funding sources should not attempt to dictate where
and how drugs and other inputs will be purchased.
Decisions on how to procure should be left to the country which may
decide to: conduct national tenders to foster competition between
generic and proprietary companies, take advantage of regional
procurement organizations or future international buying
arrangements managed by UNICEF (or other international,
intergovernmental or private procurement organisations). Efforts to
build local capacity for drug production, procurement and
management of rational drug delivery should also be supported by
international funds. Creating drug production capacity within
developing countries can be an important factor in increasing
access to medicines.
Patents must not constitute a barrier to access. The use of
safeguards (such as compulsory licensing) to override patents is
legal within the TRIPS international trade agreement and has been
strongly reinforced in the 14 November 2001 WTO ministerial
conference declaration on the TRIPS agreement and public health.
...
To offer treatment to the highest number of people possible, it is
essential that funds be used to buy quality commodities at the best
possible price. Using the lowest cost suppliers, whether
proprietary or generic companies, will increase the number of
people who can be treated and will allow for greater investments in
other important components of care and prevention. Increased
competition is a powerful tool to reach this goal. ...
V. Conclusions
* A real opportunity to impact on the HIV/AIDS epidemic now exists
* Care, treatment, and prevention of HIV/AIDS are strongly linked.
* Care constitutes an entry point and a key element for effective
prevention.
* In low and middle income countries a wide array of
life-prolonging care and treatment interventions are feasible and
cost-effective today.
* The sharp drop in the prices of antiretroviral drugs in these
countries has dramatically improved their cost-effectiveness.
Several nationwide and smaller ARV programs have shown adherence
levels and efficacy outcomes of therapy that are similar to those
in the developed world.
* Governments, the private and not-for profit sector, and the
international community must now commit the required financial
resources commensurate with the need as identified by the UNGASS
declaration.
* Failing to seize this opportunity to expand care and treatment
will perpetuate untold human suffering and increase poverty and
inequity on a worldwide scale.
We propose that this declaration be circulated to all international
and national partners in the fight against HIV/AIDS with the view
toward endorsement by appropriate forums, governments and concerned
organizations. We hope that it will serve as a basis for immediate
action.
CHAIR
Prof. Scott HAMMER, Columbia University, New York USA
([log in to unmask])
Prof. Jean-Paul MOATTI, Universite de la Mediterranee, Marseille
France - ([log in to unmask])
Prof. Ibrahim NDOYE, Institut d'Hygiene sociale, Senegal
([log in to unmask])
EXPERTS:
[full list available in on-line archive of this posting]
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