JOHANNESBURG, 20 January (IRIN) - The World Health Organisation (WHO) threw down a challenge to the international community when, at the Barcelona international AIDS conference in August, it set a target of three million HIV-positive Africans to be on antiretroviral (ARV) HIV/AIDS therapy by 2005.
AIDS activists responded with cautious optimism, not least because fewer than 30,000 people in Africa were on ARVs in 2001. WHO's target represents just half of the six million Africans who currently require ARV treatment.
SIGNS OF HOPE
A number of ARV treatment programmes were launched in 2002 by governments, private companies and NGOs, suggesting a significant shift towards improving access to ARVs.
In Malawi, the government unveiled plans to provide ARV treatment to as many as 50,000 people, bringing what UN Special Envoy for HIV/AIDS in Africa, Stephen Lewis, called a "strong quotient of hope" to those living with HIV.
The Malawians plan to use a grant from the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria to provide the drugs free of charge at public hospitals and clinics.
The Zambian government announced similar plans to treat 10,000 people, and the Kenyan Parliament opened the door to greater access to cheaper generic ARV drugs by amending copyright legislation.
Meanwhile, the Namibian government launched a pilot programme that seeks to provide ARVs to newborn babies as well as to both parents, should they be HIV positive.
The private sector also swung into action. South African mining giant Anglo-American announced it would provide ARVs to its HIV-positive workers as part of the company's expanded HIV/AIDS strategy. Other companies have vowed to follow suit.
Then, early in 2003, six multinational drug manufacturers pledged to further increase the supply of HIV/AIDS drugs to the African continent. According to the six, the number of people with access to ARVs had "increased significantly" since March 2002, although precise figures will not be available until later in the year.
The South African government, which has been reluctant to promote ARV treatment beyond a number of pilot sites, was ordered by the country's highest court to provide the drug Nevirapine to all HIV-positive pregnant women and their babies -- with immediate effect.
These and similar breakthroughs throughout the continent have contributed to heightened expectation about the possibilities for prolonging the lives of millions of HIV-positive Africans.
Sceptics have argued that effective ARV treatment was not feasible in poor communities most affected by the AIDS epidemic in Africa -- an argument that appears to have been disproved by some of the current treatment initiatives. However, other less foreseen problems have emerged.
The Botswana government's decision to provide free ARV drugs to all its citizens living with HIV and AIDS attracted considerable international attention and approval last year.
But so far the programme has made limited progress, and by December, only four percent of the estimated 110,000 MoTswana currently eligible for ARV therapy had enrolled with the scheme.
"It is a humble number, but shows how much of a challenge lies ahead," Dr Ernest Darkoh, operations manager of the country's ARV programme, told IRIN.
Most HIV-positive people in Botswana have not undergone an HIV test, and many discover their HIV status only once they fall sick. Even then, stigma and denial often prevents them from participating in the treatment programme, Darkoh explained.
"Given that most people don't know their status, people have to first get tested, deal with the psychological impact of the diagnosis, come forward to the programme, fulfil the eligibility criteria, and finally be enrolled in the programme," Darkoh explained.
People did not automatically "run for therapy" after testing HIV positive, he warned.
Those who presented themselves for treatment tended to do so only when they were very sick and required intensive care and lengthy hospitalisation to stabilise them enough to begin ARV therapy.
"Anecdotally, doctors on site estimate that with the effort it takes to treat every sick patient, they could have treated 5 - 10 patients who had come forward before becoming sick," Darkoh added.
Staff shortages in the public health sector, and the need to train health workers, further hampered the programme, Darkoh explained.
In the private sector, too, there is a growing realisation that not enough planning has been done.
In August, South African diamond company De Beers announced that it would provide ARVs to HIV-positive staff and their spouses. But, according to the company's HIV/AIDS co-ordinator Keith Markland, the company has since had to "put the brakes" on its campaign to encourage more employees to take up the treatment offer.
For starters, South African tax laws make the provision of free or subsidised medication to employees a taxable benefit. "This defeats the whole purpose of providing free drugs," Markland told IRIN.
De Beers is in the process of trying to resolve the matter with the South African Revenue Service.
The company was also in danger of falling foul of the Medical Schemes Act, as it was providing services similar to those offered by medical aid schemes.
Markland said that stigma and discrimination surrounding HIV and AIDS also made it "extremely difficult" to encourage HIV-positive employees to come forward for ARV treatment.
BOTTOM UP APPROACH
Problems such as these appear to have evaded pilot ARV programmes run by Medecines Sans Frontieres (MSF) in Khayelitsha, an impoverished township on the outskirts of Cape Town, South Africa.
Here community members, including people living with HIV, have been involved in awareness campaigns about ARV treatment, resulting in many people joining the scheme, said Dr Eric Goamaere, head of MSF in South Africa.
Members of AIDS lobby group, the Treatment Action Campaign, embarked on the "Ulwazi" (meaning "awareness" in Xhosa) project, through which they explained to Khayelitsha residents the link between HIV and AIDS, and how the disease could be prevented and treated.
The project is "extremely active" in schools, churches and other community settings, said Goamaere, who went on to warn against "top-down approaches" that tended to alienate rather than encourage people to take up treatment offers.
Goamaere feels it was important to continue rolling-out the ARV treatment initiatives and to address the problems as they arose. However, Darkoh is more cautious.
"First and foremost, you have to be sure of funding; the programme must be sustainable and robust," Darkoh said. "It would be disastrous to start a programme and then, two years later, find it cannot continue."
Furthermore, there appears to be no fix-all solution. Rather, Darkoh advises countries preparing to implement ARV treatment programmes to look critically at what works in their local settings.
"They cannot just copy our [Botswana] programme wholesale," he said. "It must be feasible for the individual country."
MSF estimates that, in two years time, the cost of treating one person with ARVs will have dropped to between US $50-80 a year. Currently, this amount of money barely covers an individual's ARV treatment for a month.
"Once the prices drop, we will see an exponential increase in ARV programmes in Africa. A tidal wave will invade this region," Goamaere predicted.
It is now up to African governments to seize the initiative, he added. "I don't think it will be easy to implement ARV treatment everywhere tomorrow. But is it impossible? I don't think so."
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