• The Keynote Speech: Ambassador Stephen Lewis, United Nations Special Envoy on HIV/AIDS in Africa
• Treating the Workers in South Africa
• Uganda -- Takin' it to the People

The Keynote Speech: Ambassador Stephen Lewis, United Nations Special Envoy on HIV/AIDS in Africa

United Nations Special Envoy on HIV/AIDS in Africa, Stephen H. Lewis, presented an intelligent and passionate assessment of the AIDS pandemic in Africa and what is required to effect real change. The 3x5 Initiative is an ambitious program developed and cosponsored by the World Health Organization (WHO) in conjunction with UNAIDS. The program goal is to get 3 million people on treatment by 2005; hence 3x5. Up until now, people have not gotten tested because, "a prognosis of death without hope is hardly an inducement to seek the prognosis." Now with this initiative, "we give people hope through treatment and with well designed programs they will [test] in ever greater numbers." WHO's aim is to fill the antiretroviral treatment gap emergency. "The initiative cannot be allowed to fail or we will have given the pandemic a license of unbridled human dissemination, greater even than that which presently exists." For the 3x5 Initiative to work, Lewis laid out the following programmatic needs:

• WHO needs an additional $200 Million in 2004 and again in 2005 to accomplish 3x5.

• We must use triple-dose once-a-day generic ART (antiretroviral therapy). The Clinton Foundation got the price to $132/person per year with an Indian manufacturer. Canada is amending PhRMA patent legislation and he urged other Western countries to do the same.

• "Involvement of community is [essential]. The key elements of the community are the people living with HIV/AIDS, who are the real experts and must be acknowledged as such. They should be consulted on every aspect of the treatment process and they should be seen as helping to mobilize the community to work in an equal partnership with the medical facility dispensing the treatment. Wherever this formula has been genuinely applied, testing increases exponentially, stigma and discrimination drop significantly and adherence rates are generally higher than they are in this city of San Francisco."

• You cannot achieve equity in 3x5 without opening the doors to women. "It is a matter of bewildering shame that even an insatiable pandemic, malevolently targeting women has failed to demonstrate once and for all the size of the gender gap and the deadly risk we face in failing to close it.

In addition to 3x5, Ambassador Lewis outlined the following worldwide needs:

• Global Fund on AIDS, Tuberculosis and Malaria must be embraced by the world.

• The developed world should spend 7/10ths of 1% (.007) of their GNP (gross national product) on AIDS.

• We must bring microbicide gels to market -- "People are dying in [horrific] numbers and the majority of those people are women." In a recent poll, only 7% of married women in 14 African countries reported condom use with their regular partner (husband). There is a growing body of evidence to show that a significant number of infected women in Africa have been infected by their husbands. "The power imbalance in marriage is too great to permit or to request the regular use of condoms. A way must be found to allow the woman to protect herself independent of male hegemony."

• "We must get a vaccine."

Ambassador Lewis concluded his powerful keynote speech with the observation that there are two things about AIDS in Africa that drive him crazy. First, the ferocious assault of the virus on women: "We are paying a dreadful and inconsolable price for the refusal of the international community to embrace gender equality. And in so many parts of the world, gender inequality and AIDS is a preordained equation of death." Second, orphans: "The orphan crisis is a crisis without parallel. Somewhere, somehow, someday the world has to understand what AIDS hath wrought. That understanding is not yet in evidence. An apocalypse has unfolded and it has to be stopped in its tracks before it engulfs us all. If morality is found wanting in the actions of governments let it be rediscovered in the advocacy of individuals."

Editorial note: President Bush's "abstinence until marriage" program (that he is imposing on Africa while holding out his conditional money) is ludicrous in light of Ambassador Lewis' telling of the increased risk for HIV infection that married women are at, compared to their single counterparts. In general, married women lose power in Africa. The notion of marriage = monogamy is a mainstream American notion, not an African one. If you want to study cultural incompetence, study the Bush White House.

Treating the Workers in South Africa

Gavin Churchyard from the multinational mining company Anglo American reported on the success of their pilot program to treat employees in Welkorn, South Africa with ART. Over 24% of the company's workforce in South Africa is HIV-positive and has no other access to medications. The pilot program enrolled 3,237 workers in the HIV program. Of those, 2,127 were started on preventative therapy such as Bactrim and TB medication; 1,222 workers were eligible for ART and 90% chose to start the regimens. The average length of therapy was 129 days. 92% reported never missing a dose. The median CD4 count was 145 at the beginning of the program and after six months of therapy, it had jumped to 409; after six months of treatment, over 60% of those still participating in the program were undetectable (<50 copies/ml). Unfortunately, 97% of the participants in the trial were male and no treatment was offered to their partners or spouses. Although Anglo American has 77 sites in two countries where voluntary testing and counseling are available, the demand for these services has been less than expected. The pilot program, however, did prove that effective treatment could be offered through clinics in resource-limited industrial settings. An interesting side note was that of the 85 men selected for treatment that declined the offer, 13% of them stated denial of diagnosis as reason for refusing treatment.

Uganda -- Takin' it to the People

Of the few treatment facilities in Africa, most are based in cities, but much of the population lives in rural settings. The TASO (The AIDS Support Organization) program from Kampala, Uganda demonstrated how to establish services for these folks. Alex Coutinho spoke of the 85% of Uganda's population that live in rural settings and how TASO is planning to get ART to such populations. The challenges are daunting: minimal existing health infrastructure and personnel with very limited access to lab testing; dispersed population with very little access to transportation; extreme poverty with minimal access to electricity, sanitation and clean water; and potential difficulty with adherence and therefore the potential for the development of antiretroviral resistance. But TASO has been serving people with HIV for seventeen years and it is only now that they are faced with introducing ART into their program that serves 30,000 people living with HIV. Their emphasis is on a family based approach, which has proven to be more successful and comprehensive than an individual approach. The family based approach holds the opportunity to broaden other aspects of HIV care, including voluntary testing and counseling, adherence support and discordance counseling. 30% of TASO's clients have partners who are HIV negative. Coutinho added that because transportation is such a barrier, "It is better to take care to people, than to ask people to come to care." Voluntary counseling and testing is done in cars that travel to rural villages. Distribution and monitoring of clients is done through weekly visits by field officers on motorbikes. The field officers provide pill distribution, adherence support, and questionnaires to elicit drug failure or toxicity and basic sample and data collection of blood smears, sputum, and stool samples, along with weekly weigh-ins. Coutinho also feels that civil society, not governments or the private sector, are better equipped to scaling up HIV treatment and that access to care has to include all elements of care, not just antiretrovirals. He echoed other speakers in emphasizing the need to keep parents alive so that their children do not become orphans. "So let us not forget, in all that we do, that we need to keep people alive not just for their own sake but for the sake of their children too."

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