TAC E-Newsletter 16 July 2001 ***************************** Website: www.tac.org.za Email Enquiries: info@tac.org.za Telephonic Enquires: 27 21 364 5489, 27 11 403 7021, 27 31 304 3673, 27 82 693 8826 Subscribe/Unsubscribe to this newsletter: subscribe@tac.org.za IN BRIEF ******** * TAC has produced the document "Pregnancy and HIV/AIDS: a practical guide" available from http://www.tac.org.za/mtctguid.doc This document is freely distributable. All readers are encouraged to produce as many copies of this document as possible and to distribute it as widely as possible. * TAC Challenge to Board of Health-Care Funders (See IN DEPTH.) * Report on some TAC activities in Kwazulu-Natal, Gauteng and Western Cape. (See IN DEPTH.) * The Johannesburg General Hospital HIV clinic is now open three days a week (as opposed to three hours). This is in response to public pressure brought by the AIDS Consortium, TAC, the ALP, CARE and NEHAWU. The AIDS Consortium has also received a detailed response from the Department of Health to its Memorandum on Johannesburg Hospital HIV clinic. The response provides a detailed description of the services available in the Johannesburg inner city. These services are clearly totally inadequate, but the Memo lays the basis for a partnership with DOH to campaign to increase resources and improve services. * The UN Human Development Report for 2001 is an indictment of multinational pharmaceutical bullying against poor countries. It calls on developing countries to strengthen their laws to allow the production of generic medicines. (See IN DEPTH, which includes TAC commentary on the report.) * Reprinted below, verbatim, is Zackie Achmat's speech to the AIDS in Context International Conference on HIV/AIDS, University of the Witwatersrand - 7th April 2001. This speech was the source of much controversy, particularly with regard to the reaction of HIV/AIDS Director Nono Simelela. We leave our readers to judge whether or not Achmat was disrespectful towards her. (See IN DEPTH.) * Richard Jeffreys debunks some myths about antiretrovirals. Also included in this report is the abstract of a study on CD4 count progress in people who have stopped taking treatment. The implication is that there is growing evidence that systematic breaks in antiretroviral treatment are possible. This has positive implications for adherence issues. * "Dead Wrong on AIDS": Attaran, Freedberg and Hirsch call for USAID Chief's Resignation -- reprinted from the Washington Post -- (see IN DEPTH.) ******** IN DEPTH ******** TAC CHALLENGE TO BOARD OF HEALTHCARE FUNDERS At the recent Board of Healthcare Funders Conference held in George, Western Cape, TAC placed five challenges before the private healthcare sector: 1. Promote equity between private and public healthcare sectors; 2. Implement mother-to-child HIV prevention programmes immediately; 3. Provide comprehensive treatment for HIV/AIDS including antiretroviral therapy (ART) and ensure that the minimum standard for antiretroviral therapy is a triple combination of such drugs; 4. Treat the HIV/AIDS epidemic as an emergency by providing all healthcare services (medical consultations, hospitalisations, diagnostics and monitoring, drugs etc) at cost price or a minimum mark-up agreed to by the BHF; and 5. Support TAC's call for an HIV/AIDS Treatment and Prevention plan. PUBLIC AND PRIVATE SECTOR INEQUALITIES Health care provision in South Africa is marked by the criteria of wealth and poverty, as well as indirect racial discrimination. Health care in the private sector rates as among the best care anywhere in the world. Public sector health care is under-funded, under-staffed and stretched to capacity. More than 80% of people in South Africa rely on the public sector that had an annual budget of R27.7 billion in 2000. The private sector covers 16% of the population with an annual budget of R35.5 billion (2000). This situation is unsustainable. In 1998, for instance, 56% of all medical practitioners (12 977) were in private practice and less than 40% in the public sector. Poor communities in urban and rural areas suffer tremendously from these disparities. Yet neglect of rural areas characterise both private and public sector health care services. Increases in private sector costs will add to the burden of the public sector. TAC calls on the BHF to support the proposals to establish social health insurance and a basic income grant of R100.00 per month for all people in South Africa as a minimum package to promote equity in healthcare services. MEDICAL AID COVER AND HIV/AIDS TAC congratulates medical schemes that are affiliated with programmes such as Aid for AIDS that provide comprehensive HIV/AIDS treatment. Their programmes give hope to people with HIV/AIDS. They provide antiretrovirals for more than 10 000 people. These medical schemes also treat opportunistic infections and they have a programme to prevent mother-to-child HIV transmission. As the prices of antiretrovirals have declined, Aid for AIDS has seen an increase in members who use ART. There is no longer any justification for any medical aid scheme to deny ART cover. Nor should any medical aid provide dual therapy because of potential drug resistance from sub-optimal regimens - triple therapy should be the standard. The only justification in the past for dual therapy was the high prices of antiretrovirals. There is sufficient evidence that ART can dramatically reduce mother-to-child HIV transmission. Every medical aid should have proper HIV/AIDS and pregnancy guidelines. Failure to provide mtct prevention in medical schemes is wrong, unconstitutional and unlawful. Antiretroviral prices: Medicines Cost per month including VAT AZT/Lamivudine & Nevirapine R1555.00 AZT/Lamivudine & Efavirenz R1508.00 DDI, D4T & Efavirenz R649.00 Crixivan & AZT/Lamivudine R1821.00 Crixivan, DDI & D4T R961.00 Source: Aid for AIDS May 2001 data It is our firm belief that antiretroviral prices can be reduced to R300.00 per month. South African generic companies have quoted triple therapy prices at approximately R250.00 per month to the state - an offer that the state has not taken advantage of partially because it will require asking brand name companies for voluntary licences or applying for compulsory licences. An additional cost that needs to be addressed is diagnostics and monitoring of HIV/AIDS and related diseases. TAC is placing the cost of these tests such as PCR, viral load and HIV testing on our agenda for generic production. Despite these advances, many medical aid schemes do not provide ART. Some limit cover even for treatable conditions. Reports suggest that some companies try to avoid their constitutional responsibilities in the provision of health care. It is unconstitutional not to extend ART coverage to people with HIV. We urge that every medical scheme present provide at least the following cover: All medical schemes to introduce mtct prevention programmes immediately. All medical schemes to introduce ARTs with a triple therapy standard. Aid for AIDS and other medical schemes have shown that these are cost-saving interventions. We are prepared to assist -- TAC has developed a very good treatment literacy model. People with HIV/AIDS and our organisation believe that the difficulties of side-effects, adherence and drug resistance are real problems. We can help through social mobilisation and treatment literacy. TAC RECOMMENDS THAT BHF TREAT HIV AS AN EMERGENCY On 12th February 2001, TAC asked the Minister of Health and the government to develop and cost an HIV/AIDS Treatment Plan before 16th June 2001. Such a plan will examine where infrastructure needs to be improved. For instance, every province in South Africa has good public sector laboratories. Many can be upgraded to provide adequate monitoring of people with HIV/AIDS. A treatment and prevention plan will cost medications (including ART), additional human resources and integrate all health care components with poverty relief and HIV prevention measures. Regrettably, the South African government has NOT responded to our proposal. On 26th July 2001, TAC will release a discussion document on the Treatment and Prevention Plan to promote awareness, action and co-operation between government, civil society, private sector, healthcare providers and international agencies. TAC requests support from BHF for this initiative. We urge all private healthcare providers to jointly make all their services available at cost price for HIV/AIDS related interventions. If this were done voluntarily by the sector, harm to the public and private sectors could be minimised at the same time as saving lives and preventing a social disaster. ENCOURAGING SIGNS Transformation of the relationship between the public and private healthcare sectors is essential. Such transformation should be built on social solidarity and risk-sharing. In addition, there was consensus between private sector providers, health-care regulators and activists that HIV/AIDS "treatment and prevention are two sides of the same coin." These were the words of Dr. Ayanda Ntsaluba (Director-General of Health) who also agreed that ART in the private sector was necessary and desirable when used with appropriate monitoring and care for people with HIV/AIDS. Support for compulsory licencing and generic substitution came from many different providers including doctors, pharmacists and medical schemes. TAC will work with the private sector to achieve equity and to ensure treatment for people with HIV/AIDS. We will also support government efforts at regulating the private sector to achieve the goals. TAC calls for a meeting with the new BHF Board of Directors to discuss the challenges of the HIV/AIDS epidemic and practical steps to address these challenges. ********************* Report on Some TAC Events ------------------------- (This is a small sample of TAC events that took place in the last few days. Future issues will contain fuller reports.) TAC Western Cape organised a number of events on Saturday, 16 July. A joint public awareness activity on mtctp was held in Mitchell's Plain Town Centre. A Gugulethu Health Forum has been established. A workshop on the Treatment Plan, the link between STDs and HIV and mtctp was held. The founding meeting of the TAC Youth Sector for the Western Cape was attended by 25 persons representing 10 youth organisations. The Khayelitsha office hosted a mtctp workshop for representatives from all the branches discussing mainly the results of the MTCT sites and its roll-out to other areas. Workshops were also organised in Philipi and Barcelona. TAC Gauteng have just successfully organised the second in a series of five workshops as part of the Nkosi Johnson Training School. Both workshops have been attended by over 150 people. Future workshops will look at such issues as woman and HIV, including risk-reduction counselling, the female condom and microbicides. Work is continuing on mtctp in the province and improving Johannesburg Hospital. TAC Kwazulu-Natal: The TAC co-ordinators gave a presentation on mtctp and the TAC Diflucan Watch programme to the YMCA branch in Zululand. The co-ordinators conducted a tour of the HIV clinics in the region and found that none of them have implemented mtctp programmes. A letter to the KZN MEC of health requesting to meet with him has been sent. TAC is awaiting his reply and date for a meeting. ************************** The Human Development Report 2001: "Making new technologies work for human development" can be downloaded at http://www.undp.org/hdr2001/ UN Report Sees Green Light for Generic AIDS Drugs By Marwaan Macan-Markar MEXICO CITY, July 10 (IPS) - In a direct challenge to the world's pharmaceutical industry, the authors of a new UN report call on developing countries to strengthen their national laws in order to enable local production of cheaper, lifesaving AIDS drugs AIDS. Such an option can be pursued legitimately under compulsory licensing, a principle in international commerce that permits countries to "use patents without permission of the patent holder in return for a reasonable royalty on sale," says the Human Development Report 2001, released Tuesday by the UN Development Programme. The international agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) includes provisions for compulsory licensing, the report notes, adding, "The agreement allows countries to include in national legislation safeguards against patent monopolies that might harm extraordinary cases of public interest." What is more, the report argues, developing countries that opt to produce AIDS drugs under compulsory licensing to combat the deadly pandemic have a strong case against drug industry giants intent on protecting their patents. "In some circumstances, such as for national emergencies, public non-commercial use and antitrust measures, the agreement allows governments to issue compulsory licenses to domestic or overseas produces of generic drugs," the report says. There is a "popular misconception" that compulsory licensing violates the rules of TRIPS, says Kate Raworth, co-author of the report. "It is not so. Developing countries enjoy the right to enact such measures through national strategies to help their people." In fact, the report states that industrialised countries have been enjoying this right for over a century, ever since intellectual property legislation was introduced in Britain in 1883. Among the countries that have benefited from the right of compulsory licensing are Australia, Britain, Canada, Germany, Italy, New Zealand, and the United States. "Until joining the North American Free Trade Area (NAFTA) in 1992, Canada routinely issued compulsory licenses for pharmaceuticals, paying a 4 percent royalty rate on the net sales price," the report states. "Between 1969 and 1992 such licenses were granted in 613 cases for importing or manufacturing generic medicines." Consequently, Canadian consumers saved millions of dollars in drug costs. In 1991-1992 alone, such savings were estimated at more than 170 million dollars. Moreover, according to the report, since the adoption of the TRIPS agreement, compulsory licenses have been used in Britain, Canada, Japan, and the United States for products ranging from drugs to computers, tow trucks, software and biotechnology. The licenses served as "antitrust measures to prevent reduced competition and higher prices." "In the United States, compulsory licensing has been used as a remedy in more than 100 antitrust case settlements, including cases involving antibiotics, synthetic steroids and several basic biotechnology patents," the report adds. On the other side of the ledger, however, the report reveals a glaring discrepancy when it comes to compulsory licensing in the developing world. "Not one compulsory license has been issued south of the equator," it states. The reason? "Pressure from Europe and the United States makes many developing countries fear that they will lose foreign direct investment if they legislate for or use compulsory licenses," according to the report. In addition, developing countries have also faced the threat of "long, expensive litigation" brought by pharmaceutical companies. Such a reality does little to help those afflicted with HIV/AIDS in poor countries, the report argues. The United Nations estimates that, of the 36 million people living with HIV/AIDS, an estimated 70 percent are in sub-Saharan Africa, with countries like Botswana, Zimbabwe, South Africa and Kenya the worst affected. Even when leading pharmaceutical companies have intervened, by offering drastically reduced prices of their anti-AIDS drugs to select African countries, the results have not impressed the authors of the report. In their view, it is a process that has fallen short of its initial promise. "Slow negotiations (between the drug companies and countries in need) run counter to the urgency of the AIDS crisis and, with terms of agreements kept a secret, some critics suspect that price cuts are conditional on introducing even tighter intellectual property legislation," the report says. For Raworth, drug industry discounts on anti-AIDS drugs are welcome but are no substitute for a strong policy to serve the afflicted in the developing world. "We welcome price reductions, but we want sound policies, not charity," she says. James Love, director of the Consumer Project on Technology, a Washington-based non-governmental organisation (NGO), says the Human Development Report's strategy to enable easier access to anti-AIDS drugs through compulsory licensing will give developing countries "more bargaining power." "It will create competition in the market once they push to manufacture these drugs, and will also help them to bargain with the pharmaceuticals on the price of the drugs," he adds. The impact of competition, in fact, has been evident since manufacturers of generic anti-AIDS drugs in Brazil, Cuba, India and Thailand have offered their products at prices far lower than what the drug industry was offering. "The price breakthrough made possible by generics has dramatically opened up treatment possibilities in the developing countries," says the report. For the strategy to achieve optimum results, however, the report underscores the need for legal structures to be created that best suite developing countries. These should include five features: "an administrative approach that can be streamlined and procedural"; an option for governments to have broad powers where "no developing country should have public use provisions weaker than German, Irish, UK or US law on such practice"; laws that permit "production for export when the lack of competition in a class of drugs has given the producer global market power that impedes access for alternative drugs"; easy-to- administer rules on compensation for royalties; and disputes settlement mechanisms under which "the onus should fall on the patent holder to back up the claims that the royalty rate is inadequate." "This is a necessary intervention," says Tracy Swan, director of the Access Project at the AIDS Treatment Data Network, a New York- based NGO. "While we do not want pharmaceutical companies to stop their research, we cannot let people die due to a lack of access to AIDS drugs. Poverty is not equal to a death sentence." ------------ Comments by TAC on, and extracts from, the United Nations Development Programme policy paper on HIV/AIDS -- Implications for Poverty Reduction (2001) -- Authors: Rene Loewenson and Al an Whiteside The paper is very useful for treatment advocacy and an integrated HIV/AIDS strategy. UNDP argues that every HIV/AIDS programme must contain at least three elements: prevention, treatment, and poverty-reduction strategies. TAC agrees with the UNDP approach. As part of an integrated HIV/AIDS programme, TAC supports: * Prevention programmes that include microbicide and vaccine research, mother- to-child prevention, the promotion of behaviour change and the use of female and male condoms; * Treatment programmes that include advice on how to live positively, voluntary counseling and testing linked to treatment of opportunistic infections and the appropriate use of antiretroviral treatment; and * Poverty reduction strategies including job creation, nutrition programmes for children and a basic income grant for all South Africans. The UNDP paper is a critical addition to all our work. Its research shows how HIV/AIDS has affected and will continue to impact on social services, households, the private sector and civil society. Every HIV/AIDS activist should study this paper. Extracts and summaries "Both prevention and treatment are top priorities in not only saving lives and reducing human suffering but also in limiting the future impact on human development and poverty reduction efforts." (p1) Selected UN Millenium Declaration Goals and the Effects of HIV/AIDS: This paper examines the negative impact of HIV/AIDS on some of the development goals set by the United Nations: 1. Reduce Income poverty: HIV/AIDS will increase consumption needs and deplete household assets. Labour losses: sick leave, productivity losses and death will reduce income. 2. Hunger reduction: productivity and income losses will further undermine subsistence agriculture in rural areas. 3. Increased access to safe water: water collection will be affected and investment in water supplies may be reduced, yet it will be critical for people who have AIDS and to prevent illness. 4. Universal primary education: increased domestic demands will force children out of school; quality of education will suffer as teachers become ill. 5. Gender equality: girls will face increased burdens and risks. Demands for labour; household income losses will increase risk of sex work. 6. Improved child health: increased infant mortality from mother to child transmission, negative impact on health care services for children. Eventual impact on all child health. (p2) The response to HIV/AIDS very often ignores poverty reduction and development: "Research has been undertaken to study the impact of the epidemic, but very little has been done about it." (p3) Premises of an Integrated Strategy: "Successful HIV prevention pre-empts the need for future treatment and impact mitigation; effective treatment reduces risk as well as impact, while mitigating impact makes individuals and communities less susceptible to risk. An effective response to HIV/AIDS must focus on all three areas of intervention. " (p5) Impact on subsistence agriculture, household income and expenditure: Small farm maize output fell by 45% when an adult died. However, when AIDS was the cause of death (long illness and care needs), maize output fell by 61%. This threatens food security. "AIDS generates new poverty as people lose housing tenure and employment. In Zambia, AIDS led to a rapid transition from relative wealth to relative poverty in many households. In two-thirds of families where the father died, monthly disposable income fell by more than 80%." (p10) "Households are reported to spend up to 50 percent more on funerals than on medical care in both Thailand and Tanzania." (p10) Poverty reduction and pro-poor policies: "The poverty impact of AIDS demands a twin response: [*] Strengthening HIV prevention, treatment and mitigation within poverty reduction strategies; and [*] Strengthening implementation of pro-poor policies to reduce the impact of AIDS." (p16) Countries must develop pro-poor policies because they "direct resources in a more sustainable manner towards low income communities ... and in so doing reduce their susceptibility and vulnerability to HIV/AIDS." (p16) "For countries affected by AIDS, sustainable poverty reduction is not easily achieved unless attention is paid in macroeconomic policies to reducing inequities, enhancing access to productive resources for a wider segment of the population, increasing the discretionary budget (by, inter alia reducing the debt burden) providing a considerable improvement in public expenditure on essential services such as health, education and safe water, and strengthening social systems and infrastructures. These are not new issues: AIDS makes them more urgent." (p17) "Furthermore, governments that perceive the mobilization of its citizens as a positive contribution towards social and economic rights can tap such organizations for the political alliances needed to deal with equity and distributional issues within the economy and for reaching vulnerable households ." (p17) Business responses: "Business responses can, in their attempts to protect themselves against the impact of AIDS, shift the cost to the state and the household. This has happened for example in the insurance sector, leaving high levels of unsecured risk at household level that is often borne by communities or by the state. Achieving equity in the distribution of household, private and public sector responses is an important challenge for all three sectors." (p19) "In 1999/2000, Botswana92s diamond mining company (Debswana) carried out an institutional audit to determine how the AIDS epidemic would affect all facets of company life and operations. At the end of the process the company had a model set of policies and responses. The model was driven by experience. Between 1996 and 1999 HIV/AIDS-related morbidity [illness] and mortality [deaths] increased. Ill-health retirements and AIDS-related deaths rose . In 1996 40% of retirements and 37.7% of deaths were due to HIV/AIDS. By 1999 the proportion had risen to 75% of retirements and 59.1% of deaths. The company hospitals recorded an increase in the number of patients with HIV related conditions, while in the workplaces there was anecdotal evidence of workers being absent or under-performing. It was at this stage that the company took a bold decision in co-operation with the workers to ascertain seroprevalence. The results were disturbing. HIV prevalence across all employees stood at 28.8 percent. The audit looked at skill levels, ease of training and replacing relevant skills, as well as related cost. It analysed risk reduction strategies for critical posts, estimating liabilities and costs associated with benefits, developing systems of productivity monitoring and consideration of potential treatment options and costs. The result was a landmark policy to cover 90 percent of the cost of anti-retroviral treatment for workers and their spouses and to require suppliers of goods and services to the company to have AIDS programmes in place. In addition, prevention measures were given top priority." ************ Verbatim Transcript of address by Zackie Achmat, Chairperson of the Treatment Action Campaign, to the AIDS in Context International Conference on HIV/AIDS, University of the Witwatersrand - 7th April 2001. ______________________________________________________________________ Good morning. I brought 4 cups cappuccinos -- unfortunately, I forgot that David [McCoy] was on the panel so he felt discriminated against on the grounds of sexual orientation and I suppose sex. But then Nono said: "I wonder what he put in it?" But I notice that most of them have drunk some of it and so I'm not going to tell what was put in it. But to tell them that I also took one of them. So may we all enjoy this session. Now, I want to speak a little bit about tradition: First, tradition is not Edwin Cameron's old ladies club, (on a Sunday night they watch movies) or it's disruptions - and I see he has a number of these old ladies club sitting next to him! Some of the others aren't here. But, tradition is a critical tool in social mobilisation and in transformation. It can play a socially conservative and even reactionary role in this process, or, we can selectively reclaim those elements of tradition that promote dignity, freedom and justice. This conference constitutes a selective reclaiming of tradition. The work of the History Workshop and the intellectuals and academics associated with this institution created a framework for the recovery of a progressive social history in South Africa. The History Workshop (HW) challenged the invisibility and absence of black people or poor people and black working class movements from official history. For almost two decades HW fashioned the concepts, representations, ideas and sometimes misrepresentations that stimulated and supported the work of the labour movement, community organisations, rural bodies, literacy classes, youth and women's organisations. But as the structuralist philospher Louis Althusser noted - Lenin privileged error in the development of knowledge and always insisted on correcting the perceived errors of others. Shula Marks, Phil Bonner (Batons and BareHeads), Helen Bradford (A Taste of Freedom), Charles van Onselen, Belinda Bozzoli, Eddie Webster and Luli Callinicos, to name a few, rigorously challenged the prevailing orthodoxy of reactionary and liberal scholars who denied black people dignity in history through racist and paternalistic conceptions. I proudly associate myself with the best work in this tradition and learn from the mistakes that we all make. It is fitting that in the 20th year of the HIV/AIDS epidemic that History Workshop should have gathered this range of scholars, activists and intellectuals to interrogate our work. We call on History Workshop to include an HIV/AIDS satellite conference in all its planned conferences for the next ten years. There is much historical research to do - not to divert from all its other, very important historical projects in the transitionary period that we need, but to ensure that HIV/AIDS remains on the agenda. I am scared and that is why I'm speaking to you today. I'm scared that without history, without courage and responsibility and above all without rigorous criticism, we will not stop this epidemic. Last year in November I received a message that a TAC activist and volunteer who had AIDS and was ill and was dying. Her name was Queenie Qiza from Gugulethu in Cape Town. She left three children behind. She lived in a shack and had no income. She asked me to come and visit. Work pressures were a convenient excuse to avoid looking a dying comrade in the face. I was scared of my own failures and facing the possible failure of the Treatment Action Campaign. I lacked the courage to face my own fears. All of us make terrible mistakes in this epidemic and this is just one that I have made. Queenie joined TAC within weeks of the formation of the organisation. She believed that we could stop the epidemic over the next generation. On the night she died, she signed 35 postcards to President Mbeki asking him to implement programmmes to prevent mother to child transmission of HIV/AIDS. Queenie Qiza died prematurely, but with dignity. This is a fact that our historians must record. TAC was formed on International Human Right Day (10 December 1998) after period of discussion about it. Less then 20 activists gathered on the steps of St George's Cathedral in Cape Town for a fast. We had two demands -- AZT for pregnant women and HIV/AIDS treatment plan from the government. We demanded that the drug companies lower their prices. On the 18th and 20th of March, this year we held our first National Treatment Congress. Mobilising more that 500 delegates (60 of them got diarrhea through the food!) and 169 organisations were represented including representatives from all the major trade unions, religious bodies, HIV organisations and so on. Over the last few days we learnt that the two sites per province of the mother-to-child transmission programme were again delayed as the Government's "research protocol" was returned by the Medicines Control Council. The conditional registration of Nevirapine by the Medicines Control Council has not been completed. Government "believed" that Nevirapine was registered for mother to child transmission. Prof. Helen Rees was reported as saying that "the media was responsible for the misunderstanding between Government and the MCC". Dr Simelela referred a decision taken by our Minister of Health and all the Ministers of Health in our country back to the Cabinet to decide whether we are going to use Nevirapine. So what is it that drives us in this discussion? What is critical for us to do is to ask Dr Simelela and to ask Dr Helen Rees not to leave here today without giving us an undertaking that tomorrow or at the earliest possible opportunity they will sit down together, bring Boehringer Ingelheim and the Minister together - because children are dying prematurely and unnecessarily. As we speak, people are dying unnecessarily and prematurely. If these people who are dying were like all of you sitting here, like myself, if they were all middle class people like ourselves - we would take a very different approach. These are poor people who are disenfranchised in the country. We ask both Dr Rees and Dr Simelela to take courage and we beg them to lead now. We will not hesitate to assert our rights tomorrow. TAC believes that we can stop the epidemic in the next generation. Research into microbicides for women and gay men will reduce new infections and they show promise but we must invest in the resources - and I think the Government has begun doing that. The development of a vaccine is critical but any scientist with integrity will say that this will not happen over the next decade. But we must invest every energy, all the resources and the passion to get that vaccine. TAC requests that before a vaccine gets tested anywhere there must be a guarantee of full free treatment for life of anyone who is infected during the period of the vaccine trials. Anything else will be experimentation on human beings. We are confident that the vaccine will come. Condoms must be distributed in their billions in the region. There are good things that the government has done, like condom distribution. I would like to ask Dr Simelela - I'm not sure what the condom distribution was for last year but before it was 240 to 300 million condoms the government distributed? When this government came to power 20 million condoms [annually] were being distributed by the previous regime, which shows the progress that has now been made. But if we divide that by the number of sexually active people in our country there are about 20 sexual encounters per person per year! So you have to choose - Dr Rees' birthday, to have sex on Professor David McCoy and Dr Simelela's birthday, Thabo Mbeki's birthday and of course David Rasnick's birthday! But with condom distribution comes responsibility; respect and responsibility in all sexual relations is a critical element that we must encourage. Such programs can assist in changing the sexual behavior. Not the boring ABC of the government. Nor, in the over-educated language in designer Love Life Ads. But, in real respectful language that people use to have sex. We can stop this epidemic. Early treatment of opportunistic infections will allow many people with HIV to live longer. This should be part of a treatment plan that commits the government to phase in the use of anti- retrovirals in the public sector over the next three years. We have asked the government for a treatment plan. Today again I ask Dr Simelela and Dr Rees to commit to HIV specific Treatment Plan before the 16th June this year. TAC militants have used songs about fluconazole and Pfizer - this is part of our treatment literacy. We have songs on AZT, Nevirapine and soon we will have songs on Co- trimoxazole. We have the will. We need the leadership from government. Bayard Rustin (whom historians will know as the black gay man and chief organiser of the march on Washington lead by Dr Martin Luther King junior) said protest confers dignity on a people whose dignity is denied. TAC believes that it is an individual's responsibility to study ethics, science law, politics and economics, medicine and history - it is the duty of every HIV/AIDS activist positive or negative, literate or illiterate and it is the key to stopping the epidemic. Our education takes place on pickets, marches and in workshops. We use handwritten posters, printed propaganda, the internet, phones, songs, pen and paper and faxes. Correct us when we make mistakes. Better even - make mistakes with us! I noticed Costa Gazi walking in as we were speaking and we welcome him. He is an enigmatic figure for me. He makes statements without having the best information available. For instance, he accused TAC of being responsible with government for the murder of babies because of the delay in the court case. These are very difficult charges and I believe we are responsible, all of us are responsible, for the continuing dying of babies. Not because of the delay of the court case, but, because of our own civility in dealing with each other. Together with our allies, Medicins Sans Frontieres and Act Up, Oxfam and many other international organisations we've challenged the giants Pfizer, Glaxo Smith Kline, Bristol Meyer Squibb, Abbot, and Roche. We will never forget that millions of people have died and will continue to die because they profiteer from medicines. They have blood on their hands and that's not my hyperbole - that's Professor Singer, Prof. Bioethics from Princeton (or one of those strange colleges in the United States). TAC showed that, whether in a court case in Pretoria on the streets of Sao Paulo or Calcutta or New York - this was a battle to stop a holocaust against the poor. Drug companies regard intellectual property rights as God given rights. Despite being an atheist I ask, did God not give life before he gave us intellectual property rights? This is the simple message that condenses all the inequalities of rich and poor, developed and undeveloped countries, men and women, into the ravages of the single epidemic. I am confident we will win. This requires your support and intervention. I ask the Chairperson of the Wits Council Mr. Justice Cameron to declare your investment in any and all-pharmaceutical companies. As an institution, examine every academic contract you have with them. Call a meeting with their directors and ask them to withdraw from the court case against the South Africa government. Ask them to be responsible investors, responsible companies. Ask them to lower prices and allow generic competition. Use your power as a shareholder to make them accountable. This is the only way to achieve sustainable access to life saving medicines over long term, that is, if all of us take responsibility. They act in your name. This is an appeal to all drug company shareholders and in particular institutional shareholders. We face a greater tragedy than the act and omissions of the drug companies. That is the failure of our government and state officials to act with courage, humility and urgency. Everyone of us has the duty to speak out when our government is wrong and to assist the government every way possible when it is right. So we ask you to join us at the court case on the 18th April because there the government is right. But let us say clearly that accusations of lack of patriotism will not deter us from a critique of "patriotic" wrong. We do not fear the accusations of racism for our accusers know that they are perpetuating racism. Racism is entrenched in our society at every level. Government economic policies that house black people in boxes; health policies that drive nurses and doctors to despair and deny poor and black people decent services; robbing black children and pensioners of income support. These are the policies that feed racism because it protects the vested interest of the financial institutions and big business. We have no truck with the opportunism of the Democratic Alliance or the buffoons Tony Leon, Peter Marais who lead them. They only discovered the causal connection between HIV/AIDS when our President doubted it. We do not act out of opportunism. The road ahead is difficult. We need infrastructure. David McCoy will eloquently explain to you the problems. But I fear sometimes that David McCoy of Health System Trust provides excuses to our government instead of encouraging them to take action. Because, very often, government uses their very good research as an excuse not to proceed with action in particular areas. To the government we say courage and humility is an important tradition of our liberation struggle. "Lead and we will follow" ************ Richard Jeffreys debunks some myths about antiretroviral treatment: It started from this posting by M.Lamson who wrote to AF-AIDS: (snip) > It seems that the treatments available for those with AIDS are very > complicated, expensive and have side effects that many cannot manage. > Providing these medicines at a lower cost to Africa sounds good but the > health care systems do not have the capacity to manage such programs. > (end snip) R. Jeffries replied to AF-AIDS with this: If [Lamson] wishes to make a judgement about the value of antiretroviral treatment in Africa (and it appears that he does for some reason), I strongly suggest that he make an effort to find out what treatment *really* involves as opposed to what it "seems" to involve. First line regimes now involve as few as 1-3 pills taken morning and night (twice daily) and can provide prolonged health benefits even if not used continuously. For example, a recent study (below) shows that an antiretroviral treatment-related increase in T-cell counts to over 600 takes an average of *two years* to decline to less than 250 (the danger zone for infections) *after* treatment is stopped. Dr. Paul Farmer, who has for some time been running a treatment program in Haiti, has seen responses wherein previously hospitalized mothers have been able to return to work and begin caring for their kids again - this echoes the experiences in the US showing that antiretroviral treatment does a good deal more than prolong illness. The most complicated regimens being used in the US are almost exclusively for people with a long history of antiretroviral treatment and resistance to many of the drugs. In places like Haiti and Africa where virtually no antiretrovirals have been available, this type of treatment history does not exist. This likely explains Paul Farmer's observation that the success rate for antiretroviral treatment in his Haiti program is higher than reported for clinics in the US. In conclusion: - The assumption that antiretroviral treatment cannot lead to a return to health is incorrect - The oft-repeated assumption that antiretroviral treatment has to be taken "for life" to produce a return to health is incorrect (although larger studies are needed to show the minimum amount of therapy that produces the maximum benefit, and it's scandalous that these studies have not been conducted since the rationale for this approach has been clear for years - Unfortunately, pulsed treatment 3D less pharmaceutical industry profit (and hence the studies have not been done) - The assumption that all antiretroviral treatments are complex is incorrect CD4 Decay after Discontinuation of Virologically Successful Antiretroviral Therapy. P.Tebas, K. Henry, K. Mondy, S. Deeks, J. Barbour, C. Cohen, and W. Powderly Background: CD4-driven "pulse" therapy (initiation and discontinuation of antiretroviral therapy at specific CD4+cell thresholds) has been proposed as an alternative strategy to the current virologically driven paradigm of HIV treatment. There is little available data about rate of decline of CD4 cells after discontinuation of therapy in patients who stop therapy with an undetectable viral load. Methods: We looked at the rate of decay of the CD4 cell count in patients who discontinued antiretroviral therapy for at least 20 weeks after being fully suppressed with potent antiretroviral therapy, in two clinical practices. Results: 31 subjects were identified (43% males, 40% white, 32+2 yr of age). The most frequent reasons for discontinuation of therapy were patient preference in 56% (most frequently in females in the post-partum), and drug toxicity (43%). The median nadir CD4 (before therapy) was 383 cells/mm3(interquartile range, IQR 244 588) and the baseline VL was 29,845 HIV RNA copies/ml. Patients gained on therapy an average 202+32CD4 cells. The median time with an undetectable VL before stopping therapy was 19 weeks (IQR, 9 38 weeks). The median CD4 cell count at stop was 635 cells/mm3(IQR 355 832). The mean follow-up after discontinuation of therapy was 50 weeks (range 20 to 119 weeks). Mean CD4 decay was 16+4 cells/month. The slope of the CD4 decay inversely correlated with the magnitude of change of CD4 on therapy (r 3D -0.527, p 3D 0.008) but did not correlate with nadir CD4 cell count, baseline viral load, type of potent antiretroviral regimen (PI based vs others), CD4 at the time of stop or gender. No patient developed an AIDS-defining event during follow-up. Two patients restarted therapy and reached an undetectable viral load again. Conclusions: In this retrospective cohort of patients, discontinuation of therapy while fully suppressed was clinically safe. The predicted average time to reach a CD4 count of 250 cells/mm3in our cohort is 24 months (95% CI 18 30 months). Patients who gained more CD4 cells on therapy tended to lose them faster. Pulse therapy strategies deserve further evaluation in the setting of prospective clinical trials. 8th Conference on Retroviruses and Opportunistic Infections *********************** Dead Wrong on AIDS By Amir Attaran, Kenneth A. Freedberg And Martin Hirsch Friday, June 15, 2001; Page A33, Washington Post Andrew Natsios, the Bush administration's new chief of the U.S. Agency for International Development (USAID), has made a very bad start with regard to one of his agency's primary missions: dealing with the scourge of AIDS in Africa. Natsios has made comments recently on the prevention and treatment of the disease in Africa that are, to say the least, disturbing, if not alarming. His comments appeared last week in the Boston Globe and in testimony before the House International Relations Committee. On both occasions he argued strenuously against giving antiretroviral drug treatment (the AIDS treatment used in the United States today) to the 25 million Africans infected with HIV. Although Natsios agrees that AIDS is "decimating entire societies," when it comes to treating Africans, he says that USAID just "cannot get it done." As Natsios sees it, the problem lies not with his agency but with African AIDS patients themselves, who "don't know what Western time is" and thus cannot take antiretroviral drugs on the proper schedule. Ask Africans to take their drugs at a certain time of day, said Natsios, and they "do not know what you are talking about." In short, he argues that there is not a great deal the agency he leads can do to help HIV-positive Africans. Under his guidance, USAID will not offer antiretroviral treatment but will emphasize "abstinence, faithfulness and the use of condoms" as the essence of HIV prevention. (He also supports distribution of a drug that blocks transmission of the disease from mother to child, and drugs to fight secondary infections.) While this might save some of those not yet infected with the virus, it in effect would condemn 25 million people to death, and their children to orphanhood. As the administration's man in charge of international assistance, including helping Africans with AIDS, Natsios should know better. His views on AIDS are incorrect and fly in the face of years of detailed clinical experience. Take the issue of whether AIDS should be dealt with by prevention or treatment. In backing prevention to the total exclusion of treatment, Natsios favors only modest changes in the strategies that USAID has relied on for the past 15 years, which by themselves have clearly failed to stem the pandemic. This is why expert consensus now agrees that prevention and treatment are inseparable -- or, in the authoritative words of the UNAIDS expert committee, "their effectiveness is immeasurably increased when they are used together." The same conclusion has been reached by countless other experts, including 140 Harvard faculty members who recently published a blueprint of how antiretroviral treatment could be accomplished. Harvard physicians are now treating patients in Haiti, and others are achieving similar treatment successes in Cote d'Ivoire, Senegal and Uganda. It is also disturbing that Natsios chooses to exaggerate the difficulties of AIDS treatment, as if to single-handedly prove it would be impossible throughout Africa. Whether Africans can tell "Western time" or not is irrelevant; nearly all antiretroviral drugs are taken only twice a day -- morning and evening. Sunrise and sunset are just as good as a watch in these circumstances. Nor is Natsios correct when he says the drugs have to be "kept frozen and all that." Not a single antiretroviral drug on the market today needs freezing. In fact, some bear warnings not to freeze them. Natsios also said that "the problem with [delivering] antiretrovirals ... is that there are no roads, or the roads are so poor." In fact, millions of AIDS patients live in cities such as Cape Town, Dakar or Lagos, where the streets are teeming with cars. Natsios says that antiretroviral drugs are "extremely toxic," so that as many as "forty percent of people . . . who are HIV positive do not take the drugs . . . because they get so sick from the drugs that they cannot survive." This is a view shared by no one in the medical establishment today. Clinical and epidemiological studies by the Centers for Disease Control and the National Institutes of Health have shown that these drugs are safe for most people and prolong life by many years. Two facts are clear. The first is that, in Abidjan and Johannesburg, as in Manhattan, AIDS prevention and treatment must go hand in hand. And we can accomplish this if the Bush administration contributes adequately to an international trust fund for that purpose (it has so far promised only $200 million, or just 72 cents per American). The second fact is that Andrew Natsios, by virtue of his unwillingness to acknowledge the first fact and his willingness to distort the true situation in Africa before Congress, is unfit to lead USAID and should resign. Amir Attaran is Director for International Health Research at Harvard University's Center for International Development. Kenneth A. Freedberg is a physician at Massachusetts General Hospital and an associate professor at Harvard Medical School. Martin Hirsch is director of clinical AIDS research at Massachusetts General Hospital and a professor at Harvard Medical School.