Malawi Plan to Control AIDS Epidemic: Interview with David Scondras of Search for a Cure
In May 2001, when David Scondras was in Malawi, the headlines in the May 19-20 Weekend Nation newspaper read, "Few on the AIDS Drugs; Babies May Be Saved; No Hope for the Poor." Almost the whole front page was devoted to the epidemic.
Scondras was there working with health experts from Malawi and the U.S. trying to change that picture -- by developing a plan to control the epidemic in Malawi, a plan that could become a model for other countries if it succeeds. While the number one goal is to reduce HIV transmission, this plan will also include medical treatment for those who need it -- and extensive operations research to make sure that the program is working effectively. This September, officials from Malawi are coming to Boston for meetings to finalize the plan and begin steps toward implementation. [The meeting was postponed after the September 11 terrorist attacks, but is still scheduled for September, with a smaller delegation from Malawi.]
AIDS Treatment News asked David Scondras to explain this project to our readers. The interview took place on August 27, 2001.
ATN: Tell us what is happening now.
Scondras: This will be the second trip that people from Malawi are making to the United States to get help. Experts and officials, including those responsible for Malawi's five-year plan to control AIDS, are coming to Boston to, among other things, meet with Jeffrey Sachs and others at Harvard's Center for International Development. They will continue a process begun several months ago in a previous trip, of having their country-wide plan reviewed by a group of scientists that Search for a Cure pulled together, and brought to Malawi as well as to Boston. Then, with the blessing of the scientific community that is reviewing the plan, they will seek funding from at least three different sources to implement that countrywide plan as soon as humanly possible.
On this trip, Search for a Cure and Harvard are hosting them in Boston for about a week.
ATN: How did this project develop?
Scondras: Two years ago when I first went to Malawi, the president of the country was on television and radio, explaining that there were some medicines that could help this disease, but unfortunately no one could afford them in Malawi, so they were going to have to do without them. This entire picture changed when we met with the Vice President and explained how these drugs work. When it became clear that lowering viral load with these drugs might help reduce transmission, it became obvious that these drugs were a necessary part of the prevention program, not just help for people who are sick. In that context people became much more determined to see that there was access to them.
Finally, when CIPLA (a drug manufacturer in India) and other generic producers offered generic drugs that were much, much less expensive, there was an increase in morale in Malawi. And when the Global AIDS Fund was announced, that morale reached the point that the vice president of Malawi accepted an invitation from Search for a Cure to come to the United States, and went to Harvard with me and met with Jeffrey Sachs and put this whole program in motion.
Malawi is determined to enact a countrywide treatment program that will stop the epidemic -- that's the objective. This will be one of the tools.
ATN: Tell us about the country.
Scondras: Malawi is a small country in sub-Saharan Africa, one third of which is a giant lake. About 70% of the population of ten million are small farmers. It has two big cities, Lilongwe and Blantyre. It is one of the poorest countries in Africa, with a per capita income in U.S. dollars of around $250 per year. It has three main Bantu languages; a major one is called Chichewa. English is a second language for most people who are educated because Malawi was an English colony.
It is a very new democracy; it emerged from a struggle to end a dictatorship only six years ago. The dictator had refused to allow the word "AIDS" to be used. The first thing the new government did was launch a prevention program across the country, with the President singing anti-AIDS and behavior change songs on television with schoolchildren to try to get people to understand that AIDS is a crisis and people had to change their behavior.
Development experts and economists came in to try to get the country going after the dictatorship ended. But they quickly realized that this country has about five years left to live. Malawi has ten million people, over one million HIV-infected. It has about 400,000 orphans who do not have HIV but whose parents are dead as a result of the epidemic. Up to a point, extended families and relatives can absorb orphans. But the ability to sustain life is being stretched to its limits as members of the extended families are now dying, as workers are dying and productivity is collapsing. The vice president compares the situation to an earthquake or other natural catastrophe, and asks why is the world so willing to help a country when there is a sudden disaster like an earthquake, but so slow when there is a crisis of equal magnitude that takes time to develop.
There has been a change. Malawi went from hopeless resignation to a sense of aggressive optimism. They decided they are going to live, and going to fight to live. This year Vice President Justin Malewezi said:
"Malawi has not been spared this worldwide epidemic. Sixteen percent of the population aged between 15 and 49 are HIV positive. These people are commonly called People Living with HIV/AIDS. However, these are not the only people living with the disease. Every day we are burying our children, our sisters and brothers, our workmates, our neighbors, our leaders, our teachers, doctors and other professionals. In the suffering and death of our brothers and sisters we face grief beyond words, sorrow beyond tears. We will not stand by and watch while our people are dying."
A study by Hamoidi and Sachs looked at how the epidemic affects individuals and families:
"To take an individual case: a husband and father of young children, who earns a market income and who becomes HIV infected. He is likely to face years of declining market income due to absenteeism from work and reduced productivity before suffering a premature death. Household income will be diverted to pay for medical care, he is likely to sell assets and borrow at very high interest rates to get minimal access to palliative care. Upon his death, funeral costs will absorb savings from the extended family while his children may be sent away to live with relatives and their future education will be severely compromised. Tragically this scenario is repeated in Malawi every day."
Malawi's plan [from which the above quotes are taken] is a direct call for help, in human terms that are unmistakable and explicit. If we don't respond to it, then there's something wrong with us. We cannot say we didn't know about it.
ATN: Once the plan is ready, where does it go for funding?
Scondras: Malawi already had a large and well-funded tuberculosis program, using directly observed therapy (DOT), with community workers who give medicine to individuals. Tuberculosis had been almost wiped out -- but AIDS brought it back. So the DOT people are willing to finance part of the program, as it affects their ability to control tuberculosis. (A recent South African study of people with HIV who use antiretrovirals vs. those who do not shows a dramatic difference of five times more tuberculosis among those who do not use the HIV drugs. So one can argue correctly that the antiretroviral program is an effective tuberculosis program, as 70% of tuberculosis patients in Malawi are co-infected with HIV.) The tuberculosis program is funded by the English contribution to the European Community.
Malawi will have a DOT program for its HIV drugs, along the line of what Dr. Paul Farmer has done on a smaller scale in Haiti. But here it will be expanded to the whole country.
A second source of potential funding will be a request from the Global AIDS Fund. The World Bank will be asked to change the payments that Malawi is presently making on its debt, which are considerable, and returning them to Malawi as grants targeted specifically for this AIDS program.
In addition, Malawi is asking for a start-up grant from the World Bank -- which has been directed to make 50% of its future investments in developing countries in the form of grants instead of loans. Incidentally, the Bush Administration is supportive of this shift from loans to grants.
There is also an effort to organize an international concert to ask for support from the world community.
And in the U.S. Congress, Congresswoman Barbara Lee (D., California) is leading an effort to contribute an additional $150 million immediately to treatment.
ATN: How would Malawi purchase the drugs?
Scondras: Malawi could use the International Dispensary Association (the IDA) as a vehicle for drug purchases. The IDA (http://www.ida.nl) is a nonprofit organization based in Holland that has had a terrific reputation over the years for being the purchaser of the most inexpensive essential drugs for poor countries. They have decided to add HIV drugs to their list. They don't just buy the drug on behalf of the country; they also test the drugs on an ongoing basis to maintain their quality. Clearly for small developing countries, it is essential to have a dependable buyer who will get you the best price and guarantee the quality of the product. Malawi may choose to use the IDA for their HIV drugs, especially since they already use it for their tuberculosis drugs.
Besides funding, other support comes from volunteers who are helping this effort and not getting paid, among them being quite a few U.S. scientists, including Peter Salk, M.D., from the Jonas Salk Foundation, and Robert Redfield, M.D., from the Institute of Human Virology, and people from the U.S. Public Health Service.
Several pharmaceutical companies are also going to try to help.
ATN: How is the AIDS program in Malawi organized?
Scondras: Over a year and a half ago we helped put together a meeting in Malawi, under the leadership of UNAIDS, which helped create the Technical Working Group, a kind of committee with the sanction of the cabinet of Malawi. This committee was given the responsibility of developing a plan to use antiretrovirals in Malawi, and overseeing its implementation. It is the only committee I know of its kind that includes foreigners on it.
The Technical Working Group includes all the major stakeholders in Malawi working with HIV, including the private hospitals and so forth. That organization is headed by the director of the AIDS program in Malawi. This is the organization that, if you are going to do anything with HIV in Malawi, you have to get approval from. Last week the Cabinet of Malawi gave the approval for moving forward.
ATN: Is there any opposition?
Scondras: The government of Malawi is fighting hard for this plan, but not everyone is supportive. There is a lot of skepticism. Part of the donor community has been trying to get Malawi to not enact this plan, still saying it's unrealistic, you should do prevention only. Malawi is going forward anyway, because it does not see any choice. Malawi knows that even a perfect vaccine tomorrow would be too late to save the country. And besides that, it would be immoral not to try to save those already infected. This struggle has not been made public, but people have a right to know about it.
ATN: What about foundation funding?
Scondras: We will be seeking a planning grant to help finish putting the program together.
Malawi wants to prove that you can stop an epidemic, and that antiretrovirals can be part of that program -- that it can be done. But the first target for this program is reduction in transmission of HIV.
ATN: Tell our readers about the research plans.
Scondras: The plan itself makes a compromise between the demands of science and the demands of the economy, ethics, and politics. The scientific community wants to make sure through research on the ground that the choice of medicines is correct, that the delivery system is actually working, and so forth -- and that the type of therapy used is the right one, and wants to see which types of therapy might be better. Should we use interrupted therapy? Does nutrition have a role? What about use of immune-based therapies? You can imagine how many questions scientists have. But it would take years to answer them all. Meanwhile the country would collapse.
So Malawi is starting the program by basically enrolling everyone into a best-guess approach -- using community-based directly observed therapy that can be taken once a day. But many people, in fact the majority, will be involved in a set of interlocking clinical trials, which the scientists refer to as operations research. These trials will test the different regimens and different styles of delivering them, to find out which work better. And as they learn what is best, they will phase out certain treatments and switch people to others.
Malawi will maintain the research component, so that Malawi will not only be a country that tries to stop the AIDS epidemic, but also will become the world's largest clinical trial system to find out the best way to reduce HIV transmission and improve on existing therapies across the world. For example, studies could test microbicides and see if they can reduce the rate of spread, or test vaccines. The research component, the ability to track data, analyze it, and feed it back to the working group and have the government make decisions about what to do, has to be much more advanced and larger than you would expect for a treatment program. The advantage is that this research will help everyone in the world, including people in the United States.
ATN: Could you summarize what's happening now?
Scondras: In a few months Malawi will make history -- as its leaders present this ambitious, countrywide program for stopping AIDS in an African country to funders at the World Bank and the Global AIDS Fund.
Malawi will not survive unless this program succeeds. Today a million people are infected, there are 400,000 orphans, and the whole country has only ten million people. If this plan works in one of the poorest countries, then it can work elsewhere and will become a beacon of hope for Africa and the rest of the world.
This effort has been put together by a team of volunteers including some of the best medical minds in the world, students from Harvard Business School, politicians, ministers, people with HIV, people of good will from all walks of life, working together with leaders from Malawi. It is possible because activists from around the world have pushed for a worldwide AIDS fund, and for reduced prices of antiretrovirals. Malawi will come to the United States to work with some of this country's finest experts and activists, all committed to finishing the design of the program and finding the funds to put it into operation now.
Anyone interested in helping is welcome to call or write us and join this effort. Many of us feel that one measure of our civilization will be how the rich nations and people of the Earth behave during the most devastating epidemic in the history of the world.
For more information about the Malawi program, contact David Scondras or Dede Ketover at Search for a Cure, 617-536-2474, or email them at email@example.com.
ISSN # 1052-4207
Copyright 2001 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.
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