Slippery AIDS Statistics: Why Loose HIV Numbers Create False Hope and Bad Policy

Attempting to treat millions of HIV patients in developing countries is a noble goal that humanitarian organizations will probably eventually achieve. Currently, however, the World Health Organization (WHO) and the Clinton Foundation are making costly errors concerning the number of treated patients and the price of drugs. These inaccuracies encourage the belief that more widespread treatment is possible. This in turn leads to unsustainable programs. Moreover, the organizations' imprecise numbers for treatment and drug pricing are encouraging the use of low-quality, insufficiently tested drugs to fight HIV. This will result in misery for those not sustained by treatment and exacerbate drug resistance problems for all who are HIV positive.

HIV/AIDS takes it toll on SA companies, but few are prepared

Study shows only a quarter of firms surveyed had a formal policy, and less than a fifth provided voluntary counselling. South African companies are starting to feel the effect of HIV/AIDS, and still have a long way to go in minimising the effect of the pandemic on business, according to a survey by the Bureau for Economic Research and the South African Business Coalition on HIV/AIDS. The survey is the largest of its kind to date, reporting on more than 1 000 firms in the manufacturing, retail, wholesale, motor trade and building and construction sectors. Almost a third of the companies surveyed said HIV/AIDS had already had a negative influence on profits, and more than half expected it to adversely affect profitability in five years. But only a quarter of the firms surveyed had implemented a formal HIV/AIDS policy and less than a fifth had voluntary counselling and testing programmes or treatment plans to support HIV-infected workers. Many South African companies are belatedly realising that they need to deal with HIV/AIDS, said coalition spokesman Leighton McDonald. McDonald said employer responses to the pandemic- appeared to be linked to company size, with most large concerns indicating that they had an HIV/AIDS policy in place and small firms having done little. The coalition said this was of -major concern because small and medium businesses were a vital source of unemployment in the country. McDonald said smaller companies were hampered in their response to HIV/AIDS by lack of funds and limited resources. The coalition intended to assist them by making its survey findings available on its website, he said. The full report, with a sectoral and geographical breakdown, is due to be published in January. Around 30% of the firms surveyed reported higher labour turnover rates, 27% indicated they had lost experience and skills, and 24% had incurred recruitment and training costs from the epidemic. Only 8% of the companies surveyed said they expected they would be able to pass on HIV/AIDS-related costs to customers by raising prices, implying that the disease would have a severe negative influence on profits and margins. Almost a fifth of the companies said they expected to be hiring buffers - bringing in extra people to shadow existing employees and learn their jobs to compensate for the expected effect of HIV/AIDS on the labour force. A recent international survey of business responses to HIV/AIDS by the World Economic Forum (WEF) painted a slightly more optimistic picture of South African companies compared to their global counterparts. The WEF said its survey showed global business was not playing a significant role in the fight against HIV/AIDS, in fact, South African companies were doing more than their global counterparts. The survey found that 43% of the 60 South African companies surveyed had HIV policies, placing SA near the top of the pile. (Source: Business Day, 11 December 2003).

SOUTH AFRICA: Is the HIV/AIDS epidemic beginning to level off?

AIDS experts have raised doubts about a new study suggesting South Africa's HIV/AIDS epidemic peaked in 2002 and was expected to level off as fewer new infections were reported. The study, published in the recent issue of the African Journal of AIDS Research, said that the epidemic in South Africa peaked last year with about 4.69 million people living with HIV/AIDS and had started to level off. It also noted that HIV incidence rates in the 15 to 49 age group had decreased substantially from 4.2 percent in 1997 to 1.7 percent in 2003. These projections were based on a new statistical model developed by Dr Olive Shisana, executive director of HIV/AIDS research at the Human Sciences Research Council (HSRC), and Thomas Rehle, an independent consultant in international health and disease control. The study used data from the Department of Health's national antenatal HIV prevalence survey and the 2002 Nelson Mandela/HSRC Study of HIV/AIDS, Dr Thomas Rehle told PlusNews. But leading South African HIV/AIDS researcher Rob Dorrington, director of the Centre for Actuarial Research at the University of Cape Town, was sceptical about the findings. Earlier studies of South African's HIV/AIDS epidemic had projected much higher HIV prevalence and mortality rates. The Actuarial Society of South Africa's statistical model - ASSA 2000 - predicts that without major behavioural or medical changes, life expectancy is likely to fall to 41 years by 2009. By then it expects that 16 percent of the total population will be infected with HIV. A report by the US Census Bureau projected that as many as 37.9 percent of sexually active adult South Africans could be HIV-positive by 2010, when there could be as many as 900,000 AIDS-related deaths each year.(Source: IRIN, PLUSNEWS, 22 October)

It takes people power

Drugs programme at AngloGold has worked better than expected so far. At last, a success story about HIV/AIDS. It comes from AngloGold, whose initial provision of antiretroviral drugs (ARVs) to its miners has exceeded the expectations of management and silenced sceptical physicians who feared workers would not take the drugs in the prescribed manner. AngloGold estimates that 25%-30% of its workforce is HIV-positive. After much internal debate, the mining giant started its highly active antiretroviral therapy (HAART) trial programme in November 2002 with just over 100 miners at Western Deep Levels and the West Vaal Hospital. Results to the end of March this year are encouraging. Public affairs manager Alan Fine says AngloGold's three main concerns have proved unfounded: - That there would be many cases of serious side-effects; - That adherence to medical orders would be low; and - That workers on ARVs would not be able to return to productive work. Most significant are the high rates of compliance, with only sporadic reports of workers failing to take their ARVs. This has surprised AngloGold's physicians, who have typically experienced compliance rates of only 20%-50% among miners on long-term medication. Kruger attributes the high rate of compliance to a programme of intensive counselling that starts two weeks before an employee gets the first ARVs. AngloGold found 90% of all company miners accepted the HAART programme. Those who declined to participate did so because of denial of their HIV status or because they thought the drugs would not help, among other reasons. Five months into the programme , 93% of the 113 people enrolled were still taking their ARVs. Of these, 57 experienced mild, manageable side-effects; but three cases of severe side-effects were also reported, including hepatitis, anaemia and severe diarrhoea. Two patients stopped treatment because of the unwanted effects. Three patients who started treatment with very low CD-4 counts were on ARVs for only a short period before dying of tuberculosis. Though the initial phase of the programme has been successful, Kruger warns of difficulties that may lie ahead. She is particularly concerned about the possible emergence of serious side-effects associated with the long-term use of ARVs. The one likely to cause the most difficulty for miners working underground is peripheral neuropathy, which causes loss of sensation in the extremities. Kruger is also concerned that adherence rates will fall over time as workers become complacent about their health. And there is always the danger that those receiving treatment will revert to risky sexual behaviour. To counteract these dangers, AngloGold is placing a renewed emphasis on HIV workplace prevention this year. It is easy to become so focused on ARVs that you neglect the bigger picture, says Kruger. The company has learnt several lessons since initiating broad-based HIV/Aids workplace programmes in 1985. They include: - Avoiding the misconception that ARVs alone will stop the epidemic; - Focusing on intervention programmes that generate behaviour change. The importance of collaborating with labour. Even though this appears to slow the process of developing the programme, it is essential to inculcate the trust required to obtain high levels of behaviour change and programme acceptance. Also the need to spend less time on risk analysis, which can easily produce unreliable estimates, and more time taking action. Given the success of the trial, HAART is now made available to all employees who meet the medical eligibility criteria - roughly 25% of the company's HIV-infected workers. AngloGold hopes to conduct 4 000 voluntary testing and counselling sessions and enrol a further 820 employees in the HAART programme by the end of 2003. Fine says the company will continue to provide ARVs to workers through its own health care infrastructure even if the state introduces a national ARV programme (see Business June 13). But workers who leave the company will have to fall back on a government programme. AngloGold, like other large companies, offers ARVs to infected staff only while they remain in its employ. (Source: Financial Mail 4 July, 2003).

Traditional culture spreading HIV/AIDS

Elements of traditional culture and subservient female roles in Kenya, Uganda and Tanzania are pushing HIV/AIDS infection rates up to unprecedented levels. In Tanzania, as is generally the case for sub-Saharan Africa, there are about 1.5 women for every male living with HIV/AIDS, Leoni Msimbe, a director from Tanzania's Ministry of Community Development, Gender and Children in Tanzania, told a workshop in Arusha. While this proportion may be somewhat exaggerated by the fact that more data is available on women due to routine antenatal tests, it is widely accepted that women and young girls are increasingly vulnerable to infection. Hilde Basstanie of UNAIDS said that girls between 15 and 19 in the region were now six times more likely to be HIV-positive than boys in same age group, often as a result of rape, coercion or sex with older men. While biology plays a significant role in the high rates of transmission man-made socio-political factors are adding plenty of fuel to the fire. Unequal Status Patriarchal culture in the region has heavily influenced the legal systems, governance structures and value systems that uphold the unequal status of girls and women. A number of commonly observed traditional practices are now recognised as being directly responsible for the spread of HIV/AIDS. Widow inheritance, widow cleansing, wife sharing, wife exchanging with land or cattle, and polygamy are some of the key ones, which are stacked against women's health because the parties involved do not test for HIV. Female and male circumcision are still practised in the traditional way, using the same knives or blades. In the case of females, circumcision can also lead to bleeding during sex. Aside from these traditional practices are the social norms which dictate that females defer to males. Male youth have been cultured to believe it is a sign of manhood to be able to control relationships. Females are brought up to believe that males are superior in all spheres of life and should be the masters of sexual relationships, said Ambrose Rachier of the Kenya Ethical and Legal Network. In adition rigid implementation of traditional practices such as dowry payments make women men's property. Sexual Subservience While men are encouraged to be promiscuous - including within marriage - women are often expected to remain pure. Furthermore, low levels of education among girls and women, due to being pulled out of school early to perform household duties or care for sick relatives, mean they cannot access HIV information. This in turn makes them totally unprepared for sexual relations, and equally unable to negotiate for safe sex. There is growing evidence that a large number of new cases of infection is due to violence in homes, schools, the workplace and other social centres, such as churches or while collecting water. Use of Condoms Female condoms have been found to be inappropriate and inadequate in the context and culture of East Africa, and have been largely unsuccessful in providing protection for women. The Ugandan Ministry of Health purchased 1.2 million female condoms but found that women were not familiar enough with their anatomies to use them.The condoms were also beyond the reach of most women, costing up to 10 times as much as the male condom. Aside from both men and women's reluctance to wear condoms within the context of marriage, in cultures where the value of women is dependent on their ability to reproduce, they are compelled to have unprotected sex, placing themselves and their babies at risk. Up to 80 percent of infections among women occurred in stable relationships where the man had become infected elsewhere. Indeed, one of the key findings of the Arusha workshop was that sex workers were often better able to protect themselves than housewives because they were more empowered to insist on safe sex. Poverty and Stigma Widespread poverty and unemployment compound the status quo by forcing women and girls to engage in risky sex with all sort of people, including their partners and husbands. Most women who are HIV positive are poor and are rejected by their husbands and families, and therefore cannot afford medicine. In some cases women are forced to take HIV tests by their husbands or families, sometimes without their knowledge, and are then rejected. HIV and poverty are mutually reinforcing - HIV pushes people into poverty, said Uganda's Minister of Gender, Labour and Social Development, Zoe Bakoko-Bakoru. Similarly, poverty places people at the mercy of HIV by forcing them to take risks. Way forward While Kenya, Tanzania and Uganda all have national frameworks to deal with HIV/AIDS, there is a consensus that more needs to be done to prioritise women's issues. Bills that are drafted tend not to adequately address women's issues - such as the Kenya National Strategy on HIV/AIDS - which have to be added later on as an afterthought. Experts say more needs to be done to protect women's rights by legalising the sex industry, criminalising marital rape and wilful infection, and imposing heavier penalties on rapists. In addition, laws protecting human rights need to be harmonised to ensure basic protection. In Kenya - in the field of family and land laws - Islamic law, Hindu law, customary and statutory laws were all working against each other, Rachier told PlusNews. Yet, the political will for change is lacking. Bills that might improve women's lot are not being passed or even debated because a male dominated parliament simply wouldn't accept them, Rachier said. In the areas of polygamy, FGM, wife inheritance and wife sharing, which are widespread and deeply rooted, he said it was not possible to introduce legislation in Kenya. Community Involvement This week, the three countries' National AIDS Councils/Commissions, UN agencies, NGOs and people living with HIV/AIDS issued a statement saying that the centrality of culture must be addressed more rigorously in each of the countries, recognising that culture needs to transform if the pandemic is to be halted. They also agreed to strengthen gender and HIV/AIDS policies and to share best practices between the three countries. The consensus is that community-based education, which includes cultural and traditional leaders, is the only means to secure behavioural change. But with so many different communities and languages in each of the countries, initiatives needs to be tailor-made to each area. Therein lies the challenge, which without adequate resources is impossible to achieve. Meanwhile, and for as long as the status quo remains, more and more women and girls will continue to lose their lives.(Source: PLUSNEWS, 28 March, 2003).