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HIVと人権・情報センター ケイト ストロネル

Caitlin Stronell, Japan HIV Center Research Resident,
Japan Foundation for AIDS Prevention

First of all, I would like to thank the Japan Foundation for AIDS Prevention for giving me the opportunity to attend this conference. Although I think many of the participants, myself included, may have benefited from a less rushed schedule, or maybe a more flexible schedule that allowed more time after the conference for those who needed it, to visit local NGOs and network with other participants, I was very happy and honored to be part of this delegation.

For me there were many clear messages that came out of this conference. I was a little surprised at the strong political flavor that was present throughout the conference, which was, I believe, even stronger than at the last conference in Durban. Even many of the scientists and doctors were saying that HIV/AIDS is certainly not just a medical problem, but rather one of political will.

One of the clearest messages, that was confirmed without a doubt at this conference, was that in fighting AIDS in the countries that are hardest hit, the poor countries, the idea that prevention is more cost-effective than treatment, that is, rich countries should concentrate funds on prevention programs rather than medication and treatment programs, was completely overturned. In the Opening Ceremony, Dr. Peter Piot, Executive Director of UNAIDS, stated unequivocally that "prevention and care are complimentary not competing priorities." He used the example of an invading army-no nation would refuse to fight an invading army simply because it would be cheaper to invest in defenses against future invasions.

There were two main reasons put forward by various speakers throughout the conference as to why prevention and treatment must go hand in hand. Firstly, it is a basic human right. According to the latest figures in the report released by the UN just before the conference, 8,500 people die of AIDS every day. What are the lives of these people worth? It was pointed out by many speakers that when 3,000 people died in the World Trade Center terrorist attack, the response of the rich world was to immediately mobilize vast sums of money and launch a war. The problem is not that the rich countries don't have the money to fight AIDS, simply that they don't have the political will. The message that each human life has equal value was reinforced in this conference, particularly by Zackie Achmat, the South African PWA who was unable to attend the conference because he has been hospitalized, but sent a video message which was screened at the morning plenary on July 10. In this message he stated:

" It is not simply the question of the cold statistics that we are putting to you, but a question of valuing every person's life equally. Just because we are poor, just because we are black, just because we live in environments and continents that are far from you, does not mean that our lives should be valued any less." Thus we have a moral obligation as human beings to give life-sustaining treatment to all those who require it, not just to those who can afford it.

The title of the Jonathan Mann Memorial Lecture, given by Dr. Irene Fernandez, the Chair of Caram-Asia, was "The Global Cry Against AIDS-Health is a Right, not a Commodity," and this speech also focused on treatment as a human right, especially in the face of economic globalization, which is turning health care into "a lucrative trade in people's health...which not only marginalizes people living with AIDS, but denies them their right to treatment" (Fernandez). Globalization and institutions such as the IMF, World Bank and especially the WTO were targets for criticism throughout the conference, with many NGOs joining in demonstrations to demand 'Medication for every Nation.'

The second reason, also brought up by a number of speakers, why treatment and prevention must be carried out together, is that treatment is actually an effective way to reduce infection. What incentive do people who are unable to obtain treatment have to get tested and find out if they are HIV positive? If they do test positive, they will simply be handed a death sentence. On the other hand, if HIV + people have access to treatment and the possibility of remaining healthy, they have much more incentive to get tested. Of course testing must be carried out in conjunction with counseling so that whether people test positive or negative, they can be advised of how to prevent secondary infection or to remain negative. Paul Farmer's work in rural Haiti shows that testing and counseling has risen five fold since the introduction of ARV in 1998.

There have been many arguments as to why treatment would never work in a resource-poor setting. Even if drugs were available, the medical infrastructure to distribute them correctly did not exist in most cases and this would lead to incorrect administration of drugs and lack of adherence which would in turn lead to drug resistance. One very strong argument against treatment was that it was just not cost-effective and would take valuable resources away from prevention programs which would in the long run save more people. Up until now there has been very little operational evidence that treatment programs will work in resource-poor settings-because no one has been willing to fund operations. But at the Barcelona Conference, the overwhelming call to respect the human rights of PWAs in poor countries by providing them with the drugs that are freely available to the rich, was backed up with evidence to show that treatment in resource poor settings does work. Not only SHOULD treatment be provided to the poor, it CAN be. I will mention two examples here-the work of Dr. Paul Farmer in Haiti and the Brazilian National AIDS Program and production of generic drugs.

Paul Farmer is a doctor based at Harvard Medical School. He has been working with a group called Partners in Health and its Haitian sister organization in rural Haiti for more than 15 years. At first their program was prevention based. They were the first group to introduce voluntary counseling and testing (VCT) and to develop culturally appropriate prevention tools in Haiti. Even though the program had some success in their area, they were finding that an increasing number of young people were becoming infected in large cities and then coming back to their home village, often to die. In 1995-96, AZT was introduced as a means to prevent mother-to-child-transmission of HIV. 90% of women agreed to VCT after that (up from between 15% and 20%). MTC transmission became rare after the introduction of AZT.

In 1998, the 'HIV Equity Initiative' was launched. ARV treatment was provided to people for whom prevention had failed and who were soon to die without these drugs. But how was this possible in rural Haiti, where many of the people live in 'indecent poverty', where the medical infrastructure and technology can only be described as primitive? For example, CD4 counts and viral loads were just not available in Haiti. The answer was community-based health workers, who visit patients in their homes every day and supervise the use of ARVs. These health workers monitor their patients directly, make daily and monthly reports on their health, as observed by the community worker and also listen to what the patient requires in terms of treatment.

Thus the impact of this program, while it cannot be shown in terms of sophisticated medical data, such as reduction of CD4 counts, etc. the results can be seen in such areas as: reduced mortality, reduced rates of hospitalization, patient charts (weight, etc.) as well as impact on patient outcomes and the burden of disease. One of Dr. Farmer's patients who asked that his photograph be shown in the presentation, comments:
"I was a walking skeleton before I began therapy...no one would buy things from my shop. But now I am fine again...My wife has returned to me and my children are not ashamed to be seen with me. I can work again." Dr. Farmer's presentation showed how a 'low-tech' HIV prevention and care project could be administered and evaluated without expensive medical infrastructure.

This work has not, up until now, been able to attract significant donor support and has been carried out through the support of patients in the US who donated their medicines, the help of students and private donations. With the hope that this project may be able to get funding from the UN Global Fund for AIDS, Tuberculosis and Malaria, Dr. Farmer mentioned there are also many challenges. He believes this money should not be spent on 'consultant fees' for 'experts' who come in from far away and introduce new and expensive ways of evaluating and reporting the program, but rather they should continue to work with the community health workers to develop lower cost methods of assessing impact, thus enabling more funds to be channeled to food, water and improved housing for HIV-affected families.

Speaking at the same Plenary Session as Dr. Farmer was Dr. Paulo Teixeira, the Director of the Brazilian STD/AIDS Program. Brazil has given the world an example of how a country with limited resources can effectively tackle HIV/AIDS from BOTH a prevention and treatment perspective and Dr. Teixeira's talk was also very inspiring.

Dr. Teixeira summed up Brazil's success in statistics:
-there are less than 600,000 PWH/A in Brazil (0.6% of the population) which is less than half what the World Bank estimated a few years ago. -the number of new AIDS cases and deaths from AIDS has fallen dramatically, the latter, especially after the adoption of HAART. The median survival time before the availability of combined therapy was less than 6 months, but now it is 5 years. QOL has also improved greatly.

-Both Brazil and South Africa had about the same HIV infection rate about 10 years ago, but the life-expectancy of the average Brazilian has been kept at almost the same level over this 10 year period.

Brazil developed a coordinated national plan to counter HIV/AIDS, directing special attention to more vulnerable populations such as MSM, IDU and commercial sex workers, as well as encouraging the development of comprehensive education programs in schools. Dr. Teixeira stated that achieving a balanced prevention and treatment approach and the firm advocacy of the human rights of people infected and affected by HIV//AIDS was one of the keys to the successful outcomes Brazil has achieved.

But how did Brazil, a nation with a per capita GDP of approximately 3,000 US dollars and areas of extreme poverty, not a wealthy country, by any means, manage to get the funds to provide its PWAs with the ARV treatment they require? As is well known, Brazil produces many of its own generic drugs instead of purchasing them at the exorbitant prices charged by the major pharmaceutical companies. Brazil has been able to bring the cost of treating its PWAs down by half in recent years, and according to Dr. Teixeira, there are two main reasons for this:

1) The Ministry of Health (MOH) made investments to set up domestic national laboratories. Of the 15 ARV drugs distributed in Brazil by the MOH, 8 are locally produced.
2) Brazil has been able to successfully negotiate with major drug companies such as Abbott, Merck and Roche to cut the prices of 4 drugs by more than 50%. "National production under compulsory licensing has been a strong argument to push these companies to the negotiating table."

There have been many calls for Brazil to export their generic drugs to other nations that need them and cannot afford to buy 'brand' drugs from the pharmaceutical companies. While Brazil wants to help as much as it can, and is involved in many and various international aid projects despite its own poverty, Dr. Teixeira explained that "redirecting our production for export would mean to fundamentally alter the mission which Brazilian public laboratories serve." He did reiterate that Brazil would be willing to transfer the technology necessary to produce generic drugs to any country at no cost.

Two years ago at the Durban Conference, the question of compulsory licensing and generic drugs was very high on the agenda. The drug companies, backed by the World Trade Organization TRIPS agreement and the governments of many of the rich nations, still seemed very strong at that time, but in the intervening two years, in the face of an epidemic that shows absolutely no sign of slowing down, it seemed to me that speakers at the Barcelona Conference recognized and were much more accepting that generic drugs are the only solution. Both Peter Piot and Bill Clinton praised the efforts of Brazil specifically in their speeches, which shows at least a tacit endorsement of the generic drug policy.

In Durban there was much criticism of globalization, global economic institutions and the so-called 'free trade' system which appears to be only widening the gap between rich and poor, and recognition that the global HIV/AIDS problem is inextricably linked with this process. In Barcelona, I feel this criticism became louder, more specific and more mainstream. Even Peter Piot seemed to be criticizing the IMF and World Bank when he said in his opening address: "Donor imposed caps on public sector spending must not fight inflation at the expense of sustained investment in AIDS."

To sum up, for me, one of the most major points made at the Barcelona AIDS Conference was that prevention AND treatment is the way to defeat HIV/AIDS and poor countries should and can have both, not just prevention programs which is what has been emphasized in the past. ARV Treatment can be made available to the millions who require it without high-tech medical staff and equipment by mobilizing community health workers and without expensive 'brand' drugs. There are demonstrated alternatives to the medical and economic 'rules' that prevail and it really is political will and community determination that will enable us to realize these alternatives.