While All Around They Die

Image: Flickr, hdptcar
Image: Flickr, hdptcar

On the impassable dirt lanes that cut through her township outside Maputo, Mozambique's capital, very few people know that Sharmila is HIV-positive.

She hopes to keep it that way – and even though she lives in the conditions that accelerate the more graphic, tell-tale manifestations of full-blown AIDS, she just might be able to. Sharmila is one of 28.2 million sub-Saharan Africans living with the virus that causes AIDS. Most, like her, live in acute poverty, where malnutrition and social disintegration enable the disease to thrive, especially among women and children, who are 2.5 times more likely to contract HIV than men, according to UNAIDS. For Africa’s poorest and most vulnerable, the countdown from infection to death can be woefully short.

But Sharmila, whose husband died of AIDS-related illnesses more than two years ago, shows no signs of living with the deadly virus. Her smile is as vibrant as her body is strong. The reason is that, unlike the overwhelming majority of infected Africans, she gets free and regular treatment through the Italian-based charity Sant’Egidio.

Roughly 15 years after the world was introduced to the life-prolonging anti-retroviral therapy, it is estimated that fewer than 75,000 Africans have access to such medicines. While governments locked horns with Western pharmaceuticals over drug prices or dithered over the logistics of broad-based treatment plans, Sant’Egidio and a few other international relief organisations are proving that treating Africa’s HIV-positive poor is both possible and affordable.

‘The lack of access to lifesaving HIV treatment in the regions where they are needed most is a scandal, and redressing that lack is one of the great moral causes of our time,’ said Peter Piot, executive director of UNAIDS, during a recent online dialogue through the International AIDS

Economic Network. More than 700,000 children – 14% of all new infections – became HIV-positive in 2003.

Three years after clubbing Big Pharma in a watershed case to cut the prices of name-brand anti-retroviral treatment, the South African government took its first tentative steps toward rolling out those drugs. At the beginning of April, 27 sites around the country had been accredited to provide the drugs. Pretoria has a lot of catching up to do.

The Sant’Egidio initiative, now two years old in Mozambique, is one of a few that have mushroomed in various parts of Africa, marking a change in thinking and tactics about fighting the devastation left by HIV/AIDS.

For most of Africa, the main message has always been prevention: abstinence, fidelity and use of condom. But this never fully achieved the required results. Infections have risen steadily over the years, especially among women. Although more than half of all worldwide infections occur in sub-Saharan Africa, not 1 in 30 HIV-positive people in that region has access to anti-retroviral treatment.

To reverse that trend, Sant’Egidio has made generic anti-retroviral treatment freely available to the poorest in a project initiated in the townships around Maputo and beyond. A church lay association, the organisation depends on private, public and individual sponsors for funding. The UniCredito Italiano group of banks has been its main sponsor thus far. The directors and many of the professional and specialised employees volunteer their services.

Through the organisation’s Drug Resource Enhancement against Aids and Malnutrition (Dream) project, the most affected population group – women – have access to free drugs and first-class support at hi-tech laboratories. HIV-positive pregnant women are given generic three-drug therapy, now combined in a single dose, from the 25th week of pregnancy, instead of the single-dose nevirapine treatment given during labour in most of Africa. The Sant’Egidio results so far have been outstanding: 97% of children born from the HIV-positive women in the programme have tested negative for the virus.

The provision of the drugs, said Mario Marazziti, spokesman for Sant’Egidio, has been a critical factor in developing more effective overall strategies for fighting the epidemic. ‘Therapy is making prevention more effective because people can find out their status and know that therapy is available,’ he said.

The Dream project is housed within existing public hospitals and maternity wards, reflecting its partnership with government. Of the 8,000 Mozambicans getting assistance through the project, more than 1,400 are on the generic three-drug therapy. These are people whose viral loads are extremely high and are in need of immediate intervention. Once they go on the full treatment, they never come off. The others receive assistance ranging from home care and medication for opportunistic infections to food parcels to meet nutritional needs.

The project has 13 centres and three laboratories in Mozambique. Sant’Egidio has just opened another facility in Malawi and has plans to expand into Angola, Guinea, Guinea-Bissau, South Africa and Swaziland by next year. Its emphasis on women is driven by a key concern: Within six years, if nothing changes, Africa will have between 20 million and 40 million AIDS orphans, according to the UN Children’s Fund and the US Agency for International Development.

Free assistance, however, does not come cheap for the Dream project. It costs the project $800 a year to give full therapy to one person. Out of that $300 is for medication, $320 for the tests and the rest for other miscellaneous costs. To lower costs Sant’Egidio is engaging big pharmaceuticals such as GlaxoSmithKline, Merck and Boehringer Ingelheim to get better deals on drugs and test kits.

Most of what is being offered through the project is what better-off countries have yet to fully introduce. Part of the problem with anti-retroviral therapy is that once a person gets on it, he or she should never get off. Doing so risks building up immunities to the drugs. An open-ended treatment programme done on a massive scale, however, is prohibitively costly – or so governments have argued. The South African government hopes to establish 53 stations in the first phase of its roll-out programme with an initial budget of less than $500,000. Health officials still don’t know how much it will cost per person or which companies will supply the drugs.

But critics raise a question of priorities. If South African can spend close to $1billion on arms, they ask, surely cost is not the primary obstacle to tackling the AIDS epidemic. During the past four years, Médécins Sans Frontières has been running a number of HIV/AIDS projects in various parts of South Africa. The humanitarian organisation is also active in Burkina Faso, Cameroon, Kenya, Malawi, Mozambique, Uganda and Zimbabwe. By the end of 2002, the group was dispensing anti-retrovirals to 50,000 people in Sub-Saharan Africa.

A critical element of effective anti-retroviral programmes, Marazziti said, is proper infrastructure. ‘We are working with the World Health Organisation to raise an alarm that no therapy programme should be started without adhering to excellent standards. You need the correct approach, otherwise Africa will disappear,’ he said.

It is also highly important, he said, to target specific groups, such as doctors, nurses and teachers, who work in vital sectors of the social and economic spheres. In South Africa, for example, teachers have been mentioned as one of the professional groups most affected by the epidemic.

‘Contexts and needs vary widely, but the core elements are always the same,’ Piot said. ‘Comprehensive efforts, which simultaneously extend HIV prevention, deliver treatment and care and mitigate the impacts of the epidemic. Above all, what is needed is a concerted attack on HIV-related stigma, which is the pre-condition for ensuring people living with HIV cannot only exercise their basic human rights, but can also take their rightful place at the core of society’s efforts against the epidemic.’

As she threads her way through the lanes and footpaths of her township, Sharmila’s feet kick up little puffs of dust with each step. In her arms rides a little girl, three-year-old Anita. Had Sant’Egidio come a year earlier, Sharmila knows, her daughter might have been spared the virus. All she can hope for now is that the organisation stays long enough to give them a shot at sharing a life together.

28 Apr 2004