AIDS in South Africa – the struggle to save poor at mercy of high drug prices

Date: 11/09/03

Providing affordable drugs for the poor has dominated preparations for this week's World Trade Organization ministerial meeting in Cancún. David Cronin reports from South Africa on the crisis facing AIDS victims - and the EU's response

THE morbid flanks the merry in Soweto. A rainbow-coloured mural, exhorting safe sex, covers a long wall leading to an orphanage in South Africa's largest township. But when you edge closer to this Salvation Army centre, you notice the sprawling graveyard opposite.

Even in hazy August sunshine, the headstones offer a potent reminder of life's fragility. And there are more reminders inside the centre. Its staff currently care for 18 children who have been diagnosed HIV positive.

Yet while the orphanage has lost 25 other youngsters to AIDS in the past decade, the prognosis is not so bleak for the current 18. Most are reacting well to the anti-retroviral (ARV) medicines they are receiving, free of charge, under clinical trial agreements with drugs companies.

Sister Theresa Mokhesi, a Salvation Army nurse, readily admits these children are "lucky in many ways". In the wider community, those who need ARV treatment would have to pay up to 1,000 rand (€124) per month. Such prices are prohibitive in a country where some 36% of female workers earn less than 500 rand per month, and the unemployed have to make do with even less.

Poverty exacerbates the health problems wrought by AIDS in Soweto (South West Township). This one-time nub of resistance to apartheid has an estimated 3.5 million people crammed into 120 square kilometres. Around 75% of houses have only outside toilets; 45% have no indoor taps.

Last year, 30,000 pregnant Sowetans were tested for HIV; results showed 8,000 had contracted the virus. This would seem to indicate that the real level of infection could be higher than statistics suggest. South Africa has the highest absolute number of people living with HIV and AIDS of any country in the world - some 4.7 million out of a total population of 45 million. Obviously, this data does not include those who carry the virus but have not yet been tested for it. Campaigners for the provision of cheap drugs to the poor calculate that AIDS accounts for 600 deaths in South Africa every day.

Soweto's Chris Hani Baragwanath Hospital is reputedly the biggest in the southern hemisphere; doctors there reckon 60% of admissions to its paediatric wards and 40% to its adult wards are for HIV-related ailments. Levels of tuberculosis, in particular, are rising.

"The first question we ask people who come in here is 'do you have money to buy drugs?'," says Neil Martinson, director of the hospital's perinatal HIV research unit. "In 95% of cases, they say they don't have the money. It's quite demoralizing."

Back in 1995, Nelson Mandela, then South Africa's president, declared: "There can be no keener revelation of a society's soul than the way it treats its children. As we set about building a new South Africa, one of our highest priorities must therefore be our children. Our actions and policies should be eloquent with care, respect and love."

His successor Thabo Mbeki appears to have been found wanting in honouring Mandela's credo. Despite the real-life horror stories about babies being born with HIV, he has dithered on introducing a nationwide ARV treatment programme. He has left countless numbers of compatriots exasperated by siding with the minority of scientists in the West who query whether the HIV virus leads to the AIDS disease.

On 8 August, however, the Mbeki government performed a U-turn. During a high-profile AIDS conference in Durban, it announced it would develop a comprehensive plan by the end of September for rolling out ARVs throughout the country.

The European Commission has been lobbying Mbeki and Health Minister Manto Tshabalala-Msimang to develop such a plan for some time, according to a spokesman for its Pretoria representation. He added that the EU's executive has been "visibly connected" with advocacy groups pushing for cheap treatment.

These include the Treatment Action Campaign, fronted by charismatic gay rights and former anti-apartheid activist Zackie Achmat. Although his health has suffered due to his HIV positive status, Achmat refused until August to accept ARV treatment - in solidarity with those who cannot afford it. He then told a Durban rally that he would take the medicines, contending it is necessary for campaigners to stay alive to continue fighting for treatment. "The most important reason is that we are not going to let Thabo [Mbeki] or Manto [Tshabalala-Msimang] kill people," he remarked.

The Commission is now in talks with the department of health on a possible EU input to the treatment strategy. "As plans become more developed by the end of September, we will consider how and where we can best support the roll-out of ARVs," a Commission official added. He explained that the Union's contribution will depend somewhat on how the government uses money from the Global Fund to fight AIDS, tuberculosis and malaria. As part of a perceived trend of reluctance to accept outside help, the government delayed for 18 months before signing a deal allowing it access to €41 million from the Global Fund in August.

Another sign of hope is that South Africa's Aspen Pharmacare has begun producing the first generic ARVs, manufactured domestically in the past few weeks. This has been due to licensing agreements with pharmaceutical giants, designed to bring the retail price down. Due to this agreement, a packet of 60 ARV tablets, Stavudine, now sells for 24 rands (€3). That is 41% cheaper than the price of Zerit, the equivalent branded drug, for which Bristol Meyers Squibb holds the patent.

Some campaigners believe that even more people would have perished from AIDS had the full rigours of World Trade Organization rules been enforced.

The majestic Table Mountain can be seen from Khayelitsha township in Cape Town. Médecins sans Frontières (MSF) could have had an even higher mountain to climb in reducing AIDS deaths among the almost 2 million inhabitants in the area. The humanitarian agency administers a cocktail of drugs to those whose T-cell count has fallen below 200 (the point at which someone develops full-blown AIDS; most uninfected people have T-cell counts of 600-800).

Marta Darder, the coordinator of MSF's access to medicines campaign in Khayelitsha, says that on average most of those being treated initially have T-cell counts of 42 and are already quite ill. But after six months of treatment the mean level increases to 175, with many then going on to register higher than 200 T-cells.

The most visible manifestation of improving health is that those who have incurred severe weight losses typically put on more than six kilos once six months have elapsed. Despite the dire poverty and low education rates in Khayelitsha, doctors have been successful in convincing patients to take medication. "The argument used here is that people here will not take tablets because they live in shacks," says Darder. "But that is not what we see. We have good results. Almost 90% of people keep taking at least 95% of the tablets prescribed."

The drugs administered by MSF's doctors are generics, imported from Brazil and India. Darder says that drug companies could sue the organization for breaching the WTO's trade-related intellectual property rights agreement (TRIPS), but have chosen not to do so.

MSF is now trying to provide a similar service in a project it has set up in the rural setting of Lusikisiki in Eastern Cape province, among the poorest areas in the country. This is a challenge, as disseminating information is far more difficult there for logistical reasons than in a built-up township.

An added problem - which applies throughout South Africa - is that many fear they will be ostracized if their relatives and neighbours discover they have the virus. Tentative work in Eastern Cape, however, indicates people are willing to come forward to be tested for HIV and receive treatment if necessary.

"The burden of disease, death and suffering is so high in such places that people are able to face the problems," explains Darder. "There's a good attempt to break the stigma, to break the silence."

http://www.wto.org/english/thewto_e/minist_e/min03_e/min03_e.htm http://www.wto.org/english/thewto_e/minist_e/min03_e/min03_e.htm

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