CHAPTER 9

This, of course, raises the critically important question of where these resources are to come from, "to eliminate poverty." For those who think that the route of the extensive distribution of anti-retroviral drugs is the most affordable, they should take heed of what an IMF staff study had to say.

The newspaper, Business Day, reported on November 15, 2001 that:

" No southern African nation will be able to offer general access to antiretroviral treatment for HIV/AIDS through its public health service, even if the drugs are available at marginal cost, concludes a grim new International Monetary Fund (IMF) staff study.

" SA and Botswana are possible exceptions, but 'only to a limited extent', says the study's author, Markus Haacker of the IMF's research department, in an analysis that highlights the quandary faced by SA policy makers.

" By 2010, Haaker estimates, the cost of providing highly active antiretroviral treatment to 30%, or less than a third, of South Africans who need it would represent about 1,4% of gross domestic product (GDP).

" With just 10% of those needing the treatment receiving it, the cost of all HIV-related health service for SA would be close to 1% of GDP in 2010, equivalent to nearly a third of public health expenditure in 1997.

" Haaker concludes that even getting antiretrovirals to 10% of patients will be difficult. 'Given the serious shortages in personnel and infrastructure the health sector is facing, the scope for alleviating the (effect) of HIV/AIDS on the health sector through financial aid is limited."

In the article we have already cited, Dr Laurence of "The AIDS Reader" also says:

" In addition, these 2 (US) studies did not consider the economic costs of resistance testing and medication adherence monitoring, as well as public health consequences should these issues not be an integral part of all economic discussions of HIV/AIDS. This omission will have a great impact worldwide if recent calls are heeded and wide distribution of ART (anti-retroviral therapy) in Africa and similar areas being decimated by HIV occurs without adequate oversight of medication adherence.

" Many factors may facilitate such resistance, but patient noncompliance and drug interactions are key. Arguably, these confounders can only be exacerbated in the developing world, in the setting of poverty, instability of social structures, and lack of health care resources.

" In the United States, spread of resistant strains may be mitigated by genotypic and phenotypic resistance testing. Like ART itself, these assays are cost-effective in some instances. But they could double the cost of many ART regimens. This will confound future assessments of the economies of HIV treatments in the context of public health predictions for the growth and medical impact of resistant strains.

" In 1993, when HAART was not yet conceived, an editorial appeared in the Annals of Internal Medicine entitled, "The hazards of misguided compassion". It addressed the issue of rapid, unmonitored dissemination of 2-drug ART in the community before what the writer felt was sufficient clinical testing. We now know that such use had a very small impact on life expectancy but promoted resistant viral strains, which persist for the life of the patient. Based on this experience, I would argue for limited and monitored distribution of free or low-cost ART in those regions where, based on poor existing infrastructures or known problems with treatment of other communicable infections such as tuberculosis, it is least likely to be of benefit to the individual or the community.

" (Statements about affordability) and the quality of existing infrastructures, must receive careful review and updates, based both on economic valuations and on public health considerations, in the design and dissemination of ART worldwide."

The WHO supports this conclusion when it says:

"However, it should be noted that drug costs may represent only a fraction of the costs of the services that are required for an effective MTCT-prevention programme." (WHO/RHR/01.21). (Our emphases).
The fact of the matter, however, is that the omnipotent apparatus has succeeded to convince everybody that all that needs to be done is to reduce the price of the drugs, and all problems of cost will be solved!

Taking advantage of this, some of the pharmaceutical companies have sought to capture particular markets, especially in the poor countries, by offering to donate their drugs free-of-charge, for particular periods of time. The manufacturers of nevirapine/viramune, Boehringer-Ingelheim, have offered our country a free supply of this drug for five years.

Our national Ministry and Department of Health have not accepted this offer. Nevertheless, some of our provinces have been both proud and loud to announce the acceptance of this offer.

The leadership in these provinces is happy to ride a crest of dangerously misinfomed popularity, in fact to threaten the health, and lives, of our people, while claiming to be acting in the interest of life itself. This is a matter that has to be dealt with strongly and in a principled manner.

For now, we will only report on WHO Guidelines relating to the issue of "Managing Nevirapine Donations". These guidelines appear in the 2001 WHO document entitled "Prevention of mother-to-child transmission of HIV: Selection and Use of Nevirapine: Technical Notes."

Among other things, this document says:

" The drug donation should be based on an expressed need and should not be sent without prior consent of the recipient country.

" The programme should not be promotional in character, or increase market opportunities for a specific commercial enterprise to the detriment of others;

" The donation should be based on a sound analysis of the recipient country's needs, and the selection and distribution of nevirapine must fit within existing policies and guidelines on MTCT-prevention; the standards of the MTCT-prevention programme must be promoted; health workers must be trained and systems for supervision, and monitoring and evaluation must be put in place;.

" The additional costs to the recipient country should be calculated in advance and funding arrangements made;

" Financing mechanisms for ensuring sustained access to nevirapine beyond the five years of the donation programme should be defined."

The WHO document says all these guidelines, and others, "require special attention in the case of the nevirapine donation"!

The pharmaceutical company concerned has deliberately and consciously ignored all these Guidelines. Consciously and deliberately, it has decided to treat our government and country with contempt. It has taken the decision that both what the government our people have chosen and the decisions they take, are immaterial to what it decides to do in our country.

Like some NGO's funded by the "haves", it has understood the phenomenon of self-repression among us and the instinct 'to love to look upon or to be noticed by the possessor of Power or Conspicuousness'.

It has understood what poverty does to people, driving them to think with their stomachs rather than their heads. To gain material advantage, the privileged poor among us are quite ready to transform themselves into defenders, representatives and sales agents of the Powerful and Conspicuous.

The privileged poor know that the latter will reward them with dollars. They do not care what happens to the powerless and inconspicuous they claim to represent! As with their paymasters, what makes their world go round is - money, money, money!

Because of all this, the manufacturers of nevirapine have acted in our country in a manner they would not dare in the developed world.
Pressure on our government to ignore the WHO guidelines will not come from the company. It will come from those among us who have accepted the need for self-repression, who tell us everyday that what the pharmaceutical companies say, is correct and should be , acted on.

As the Chicago NGO, AIPAC, undoubtedly supported by our own Glenda Gray, said in relation to the drugs Videx and Zerit, we must accept that the manufacturer is 'a global health and personal care company whose mission is to extend and enhance human life'!

What our people are about, both black and white, to decide what happens to themselves, their children and their country, demands that they decide what they do with their health. This requires that they think independently.

They must refuse to be bribed or intimidated as some presume that because they are poor, and by definition deprived and dis-empowered, they are ready to be bought and terrorised.

Difficult as it is, the possibility to think independently must also apply to the question of HIV/AIDS. This, too, is about what happens to us as a people. It has to do with our physiological health, our psychological health, our political health, our assessment of ourselves as Africans.

And so we come to the questions which the omnipotent apparatus decrees should not be asked.

Since the US government does not recommend nevirapine for MTCT, on what basis are we being asked to use this drug for MTCT?

Since its safety relative to the child has not been established, why are we being asked to give it to our mothers and children?

What do those who argue for the efficacy of nevirapine in MTCT base this conclusion on?

Given the difficulties associated with determining the HIV status of infants, how is this status determined in our country?

What study exists in our country that measures comparative infant mortality between 'HIV-positive' and 'HIV-negative' infants?

What is meant by an AIDS-orphan - how are these scientifically determined as 'AIDS-orphans' as opposed to mere orphans?