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Posts Tagged ‘South Africa’

This video chronicles the true story of Selinah, an HIV/AIDS patient in South Africa who experiences the ravaging effects of her disease being reversed through ARV treatment over a period of three months.  Produced by the advertising agency Ogilvy Johnannesburg for the HIV/AIDS relief organization, the Topsy Foundation, the short film won the coveted Cannes Gold Lion award at the 57th Cannes Lions International Advertising Festival last week.

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Here at the Microbicides 2010 conference in Pittsburgh I got a chance to talk with Dr. Gita Ramjee, one of the top researchers in the field, about the most exciting scientific challenges being discussed at the meeting.  Dr Ramjee is the Director of the HIV Prevention Research Unit at the South African Medical Research Council.  She also explains in the interview why development of an effective microbicide for rectal use is so crucial, for both men and women in Africa, in particular given higher than expected rates of reported anal sex in several countries, as well as in many other regions of the world including the United States.

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This excellent New York Times story makes clear that, when it comes to battling AIDS, it really is a new day in South Africa. But even as the South African government unveils an impressive new plan to ramp up HIV treatment and prevention, a new report from the International Treatment Prepardness Coalition makes it equally clear that the donor-nation commitment to fighting AIDS is far from secure.

The ITPC report documents emerging signs of treatment rationing, as a result of the U.S.’s decision to flatline funding for PEPFAR, the world economic downturn, and a more general backlash against AIDS. Click here to read the full report or here to read a Reuters story on the report.

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Dr. Eric Goosby, the US global AIDS ambassador, spoke with John Donnelly about a number of issues surrounding PEPFAR and the Obama administration’s new Global Health Initiative, including how the administration hopes to ramp up treatment and prevention efforts with small increases in overall funding and how PEPFAR is constantly responding to emergencies in the field – including the move in December to give the South African government $120 million after the country had an unexpected funding shortfall in nine provinces.   

Q: Roxana Rogers, USAID’s South Africa health team leader, said recently in South Africa that, “US government funding is going to come down dramatically over the next five years.” True?

A: No, it’s not true. Every year there’s been an overall increase in funding for PEPFAR, and we’ve also not been in a situation where we’ve had a decrease in any country, certainly not in South Africa. Our funding for South Africa is over a half billion dollars a year. Our resources that go into South Africa are having a huge impact, and I’m not understanding that (comment by Rogers).

We also committed to $120 million recently over two years to specifically address an unexpected shortage of funding for antiretroviral drugs in South Africa in nine provinces. The South African government asked us to be silent (about it during that time.) … It made a lot of sense for us to fund it for the simple reason that we not allow services to be interrupted and allow South Africa to respond to the increase in demand.

Roxana’s statement is based on the fact – I think – that she was used to PEPFAR funding that went up in huge increments every year — so much so they scrambled to find meaningful applications to use the funding for programs. Now we are in an economic crisis, with nowhere near the increase in funding like that, so on a relative level it may feel like a drop in funding.

Q: What happened in South Africa’s shortfall of funding for treatment?

A: PEPFAR has not run out of any antiretroviral drugs in any country, including South Africa. .. But for multiple times we’ve been asked to bail out a country for one or two months (because of drug shortages in the national program or funding shortages). South Africa had run out of resources to pay for the medication in nine provinces, starting in November. It was a significant outlay of resources for us and a real example of cooperation. In addition, we were able to work with the government to ensure their Treasury picks up the bill thereafter, so it doesn’t happen again.

Q: You have said, “Our commitment to universal coverage hasn’t wavered.” With the increase in demand for treatment and prevention around the world, how can you make that commitment with just a $141 million increase in your budget – and with some of that money earmarked for the Global Health Initiative?

A: We are committed to universal access. We are partnering with implementing countries to mount their response. Our expectation was never that we would be the sole source of funding to fight the epidemic. … PEPFAR or any other single funding line will not be able to successfully respond to the unmet need. … It’s not within one single program’s ability to mount that response.

I don’t know if PEPFAR ever presented itself that it was going to cover the entire need for prevention, care, and treatment for any country. We are definitely providing larger than the bulk of the funding – 50, 60, or 70 percent of it– in our focus countries already.

Q: You have talked in the past about finding savings in PEPFAR’s budget that would free up additional funds for treatment and prevention. What are you doing in finding these savings, including in trying to reduce the price of ARV medication?

A: We have been in long-term negotiations in every country we’re in to have the predominant purchasing (for drugs) occurring with generic manufacturers. We saw a shift two years ago, and now we’re in the high 80s, low 90 percent (of all drugs being generics) We have had discussions with South Africa … and they needed to move from  about a 65 percent brand dominance to somewhere down to 10-15 percent range, which they have started to do.

We are engaged with the Clinton Foundation to look at generic pricing arrangements, toward a commitment that creates and introduces a competitive component to generic pricing. After that initial deal is cut (in a country for generic drugs) competitive pressure from another generic manufacturer in that region will continue to drive that price down.

For other efficiencies, we have looked at the Clinton Foundation and Synergos (Institute in New York City) and other organizations that have a history of this type of work. We try to understand how we can use the experiences they have had with other countries, not with PEPFAR, to learn lessons that enable us to identify efficiencies for treatment and for prevention interventions.

Q: You are now helping to create partnership forums with countries on the HIV/AIDS response. How will you be able to ensure the representation of civil society groups in situations like the one unfolding in Uganda now – with the proposed law that would outlaw homosexuality?

A: PEPFAR has played a central role in being the dominant response in Uganda to the epidemic. We are now and always have been treating gay men in Uganda. Whether the country has admitted that or acknowledged that is a different issue — they never have. From day one, the Infectious Diseases Institute and TASO (The AIDS Support Organization) have been central in that response, and that will continue. In addition, PEPFAR is in a position to play a role in the partnership frameworks to engage in a substantial dialogue with country leadership about the public health impact from such a law. … With such a law, there is a fear that this will stop the flow of patients into testing and into treatment. We will always fight against that in the way our programs are implemented. PEPFAR also has an opportunity to identify – and fund – higher risk populations.

Q: How does that strategy work?

A: We could fund non-governmental organizations that do outreach, that create support groups. … Then there is a growing number of individuals who feel safe and who are willing to take those risks who coalesce in a group that can be funded as a separate NGO. In China now, there is an increasing number of NGOS created specifically for high-risk groups, especially men who have sex with men. … There is a need in creating these safe islands of safety so they can be tested and treated.

Q: For many years, you were on the outside of government, an activist, giving advice to those in power. What should activists be focusing on today?

A: Activists have played from the beginning of the epidemic a central role in reflecting a conscience for policymakers and for governments to understand their responsibility in orchestrating an effective response to this epidemic.

What I think is most needed today is for advocates to look at the larger picture of responsibility, i.e., who is responsible for the response, and to start to talk about it as a shared responsibility, not just dependent on any one country to model a response, but (about the US) playing an appropriate needed role as a world power, an economic power, a political power.

Also, the advocacy originally in the US was by those most impacted by the disease. There needs to be advocacy now coming from the infected and affected communities in countries where we’re most engaged.

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Okay, so funding for PEPFAR and TB programs did not get top billing in tonight’s State of the Union address. With the economy still sputtering, with voters anxious about the next paycheck and angry about spiraling deficits, global health wasn’t exactly a political winner in tonight’s speech.   

But President Obama still did squeeze in a mention of the issue, even specifically citing US efforts to combat HIV/AIDS, highlighting a “new initiative” against bioterrorism and infectious diseases, and articulating a commitment to strengthening “public health abroad.”  Obama’s quick rhetorical nod came amid deep worry among HIV experts and activists about this Administration’s commitment to maintaining scale-up of treatment for AIDS–anxiety that was only deepened today by some news out of South Africa.

Here’s what Obama said tonight about America’s role  in foreign aid in general and  global health in particular:

“That is the leadership that we are providing – engagement that advances the common security and prosperity of all people. We are working through the G-20 to sustain a lasting global recovery. We are working with Muslim communities around the world to promote science, education and innovation.

We have gone from a bystander to a leader in the fight against climate change. We are helping developing countries to feed themselves, and continuing the fight against HIV/AIDS. And we are launching a new initiative that will give us the capacity to respond faster and more effectively to bio-terrorism or an infectious disease – a plan that will counter threats at home, and strengthen public health abroad.

As we have for over sixty years, America takes these actions because our destiny is connected to those beyond our shores. But we also do it because it is right.” (For full text, click here.)

These few words were welcome, particularly coming on the heels of a disconcerting story about of South Africa today, in which a US official warned of deep cuts to US global AIDS funding. 

“US government funding is going to come down dramatically over the next five years,” warned Dr Roxana Rogers, USAID South Africa Health Team leader last week, according to this story. “There is not a friendly feeling in the US towards more funding for HIV/AIDS,” Rogers told a meeting in Cape Town on the future of US assistance for HIV/AIDS, hosted by the US-based Council on Foreign Relations. Here’s a link to that full story.

US officials tried to quickly to “correct the record” by issuing this statement, which says the US is “fully committed to the multi-party effort led by the Government of South Africa to fight HIV and AIDS in South Africa” and adding these funding figures: “In South Africa, PEPFAR support from 2004-2009 has totaled over $2 billion (R15 billion), representing the largest contribution from PEPFAR to any country.  In 2010, PEPFAR will add $559 million (R4.2 billion) to the cause in South Africa. “

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When Gilbert Tene, a Rwandan pediatrician, first examined Joseph, the 9-month-old baby boy had acute pneumonia and severe failure to thrive. His short life had already been marked by repeated episodes of illness—fevers, diarrhea, coughs. He was severely malnourished, weighing only about 12 pounds, and could not sit steadily by himself. His diagnosis: advanced HIV disease (WHO stage 4).

Treating HIV/AIDS in resource-poor settings is hard enough, with health worker shortages, drug supply glitches, and other hurdles hindering quality care. But when the HIV-positive patient is an infant, the job is even more daunting. There are obstacles at every turn, from individual patient diagnosis to case management to weak underlying country health systems, says Dr. Tene, a pediatric HIV specialist with Columbia University’s International Center for AIDS Care and Treatment Programs (ICAP) in Rwanda.

Take, for starters, the unreliable access to appropriate HIV diagnostic tests for infants, because of cost and other factors. Then, there’s the lack of infant and child formulations of the most commonly used first-line ARVs.

Stellenbosch University's Helena Rabie, MD, provides hands-on training in the complexities of pediatric HIV care to Kedise Shenbut of Ethiopia

Sometimes you have to work out dosage by measuring a child’s body surface area and make adjustments as a child grows, says Mark Cotton, MD, a professor of medicine at South Africa’s Stellenbosch University and a pediatrician specializing in HIV care. A health care clinic’s staff must have the time, the equipment, and the ability to accurately weigh a baby, translate that weight into a new drug dosage, and then explain to the mother how to measure the adjusted dose.

And a key drug in the ARV regimen prescribed in many resource-poor countries, lopinavir/ritonavir (also known as Kaletra), is sometimes not well tolerated by children because of the terrible taste. “How about a combination of battery acid and bile?” Dr. Cotton offers when asked for a description of the drug’s taste.

It’s no wonder some kids spit it up. While there is a tablet form of the drug, it’s very large and cannot be cut or crushed, which would make it easier for a child to swallow. “Another problem is that medicines we would prefer to use because of better efficacy are too expensive,” Dr. Cotton says. (For example, many doctors would prefer to use abacavir instead of stavudine, which is much more toxic, but it’s about 20 times more expensive and simply not available for wide use in South Africa or other poor countries, Dr. Cotton says.) (more…)

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It seems there are still more questions than answers about how PEPFAR will achieve a key milestone—recruiting and retaining 140,000 new health care workers over the next five years in countries hard hit by the AIDS epidemic.

Congress included that provision when lawmakers reauthorized PEPFAR last year, part of a broader effort to strengthen developing countries’ health systems. But turning that promise into a reality is a tall order, given the severity of current workforce shortages, the time, effort and expense involved in training new doctors and nurses, and the brain drain of health care professionals from resource poor countries to more affluent ones.

During a presentation at the Global Health Council today, Karin Turner, a senior USAID official whose portfolio includes health system strengthening and heath care workforce issues for Southern Africa, said there was still some “fogginess” on how this effort would unfold in the context of PEPFAR’s pivot to focus more on health system strengthening.

Some of the uncertainties Turner highlighted:

*Will program officials and implementers be looking more at general health outcomes or HIV outcomes under the new PEPFAR law?

*What is PEPFAR II’s vision of health systems?

*Will the focus be on building sustainability or meeting new targets, or both? (more…)

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