Important note: Information in this article was accurate in June 2000. The state of the art may have changed since the publication date.
A decade after the fall of apartheid, South Africa is working to resolve the political and financial aftermath of more than a half century of institutionalized inequity. Though the wounds are slow to heal, past injustices are being redressed across the board, and the country's constitution now ranks among the world's most liberal.The biggest challenge now facing this nation of 40 million is one that collectively encompasses economic, social, political, and health issues: HIV/AIDS currently affects nearly every citizen either directly or indirectly, with 1,500 to 1,800 new cases diagnosed every day. The South African government could not have predicted that the greatest threat to its future stability would be a growing epidemic. Recent newspaper editorials by government ministers estimate the present HIV prevalence at a staggering 20% of the South African population.
And the numbers are increasing. One recent projection is that one-third of the total South African population will be HIV-positive by the year 2010. Rural communities are hardest-hit: nightmare scenarios of whole villages turned into ghost towns, overcrowded clinics with too few beds, and overwhelmed hospital staff hopelessly ill-equipped to handle the deluge of terminally ill patients, most of them under 35, are commonplace in predominantly rural provinces like KwaZulu-Natal. Burials and cremations in that province's city of Durban – site of the next International AIDS Conference in July – have risen 250% over the past three years.
The bulk of South Africa's economically active labor force hails from such rural parts of the country. "What we are seeing is nothing less than imminent full-scale economic disaster," says Dr. Ian Sanne, head of the Infectious Diseases Clinic at Johannesburg's University of the Witwatersrand. The ramifications for Africa as a whole would be devastating.
Dr. Sanne urges that industry and government work together. "They have to accept that we need antiretroviral therapy in this country, while there's still time to act effectively. The political will needs to shift cohesively to a holocaust mentality."
President Thabo Mbeki's government, on the contrary, has taken the bewildering official stance that unless AIDS treatment can be made affordable to all, it should be withheld from all. Mbeki is under fire from the AIDS community for refusing to fund badly needed AZT treatment programs for pregnant mothers, rape victims, and hospital staff accidentally exposed to the virus through needle-stick injuries. In response to such proposals, Mbeki has cited his belief that AZT is too toxic for regular use. He has also questioned whether HIV does indeed cause AIDS.
Dr. Sanne believes the South African government first needs to abandon its current unreasonable attitude before it can create any solutions. "Of course, we ideally want access to therapy for all," he says, "but we cannot wait for equitable access for everyone, before we start treating someone."
Return to topAZT, which costs a little more than half a South African rand ($0.07) per tablet to produce, sells in South Africa for R2.79 ($0.35.)per tablet. This amounts to a current monthly cost of some R500 ($71) per patient, a figure well out of reach of the average South African worker, whose salary is often less than $200 per month. Dr. Sanne is adamant that the only way to avoid full-scale economic meltdown in South Africa in the short term is to treat its economically active citizens first: "Impact studies in the mining industry alone prove it's crucial that we start with the people who are the backbone of this economy. The answer lies in making drugs more affordable to these individuals. [Drugs like] AZT need to be provided to them immediately."
South African activist groups have been going head to head with the big drug companies for several years, lobbying for greater drug access for all. But Dr. Sanne feels they have possibly been approaching the problem from the wrong end. He is convinced that the only real way to ensure an improved supply of badly needed drugs in South Africa is in fact to work with the big drug companies, not against them. By appealing to their wallets and assuring them that their profits back home would remain inviolate, South Africa stands a better chance of winning them over.
Although he does advocate generic replacements, Dr. Sanne thinks it important to concentrate in tandem on reducing existing suppliers' prices. The pharmaceutical industry, he believes, is in fact shifting toward better access in the Third World. "They seem to be listening to activist groups like Médecins Sans Frontières and our local TAC [Treatment Action Campaign]. They're slowly waking up at last to the dire nature of the situation, and their attitude can definitely be changed if approached from the right angle," he says. "When and where possible, we want to take real drugs in South Africa at a lower market price, and the current softening climate will hopefully ensure that this can happen."
Dr. Sanne is greatly encouraged by Glaxo's recently announced intention to reduce the price of AZT, 3TC and Combivir by up to 80%, but the situation is still seriously hampered by the government's attitude toward antiretrovirals in general. Since the state won't pay for antiretrovirals, it makes little practical difference how cheap the drug companies like Glaxo Wellcome may make the drugs at the consumer level.
"With the new price reduction," says Dr. Sanne, "AZT for example will now be offered to the South African government for the price of R200 per month per patient, well below the current R500 per month. If the government would only come around to agreeing on the very real benefits of AZT, then this could potentially more than triple the number of pregnant women who can currently afford AZT in the last month of pregnancy."
Return to topDr. Sanne is developing a business plan that he hopes will spearhead the drive toward more affordable drugs for all South Africans. His first step concerns all-important patent rights. In the case of old patents, Dr. Sanne is pushing for South African manufacturers to be allowed to obtain the rights to produce these drugs in a much cheaper form (i.e., generics). That form should be distinct enough from the real product in terms of packaging and formulation to discourage black-market exportation to Europe, a prime source of worry for the pharmaceutical companies.
Newer drugs that do not meet the US FDA's criteria of "equivalence or superiority to existing drugs" would be targeted, too, in the hope of taking over their patents and manufacturing them locally at significantly lower expense. Dr. Sanne points out, "Just because a drug may be superceded by a newer version, that doesn't necessarily make the original drug any less effective." In both instances, patents would be held by the non-profit academic world. He contends that part of the strategy would be research. Results from continuing trials with these drugs would further benefit the pharmaceutical companies themselves.
A second step in Dr. Sanne's plan involves the development and implementation of a direct drug distribution network to patients, via the Internet. "South Africa has a highly developed, efficient network of courier systems, and these can be linked up with existing medical distribution companies via an Internet pharmacy to deliver medications door to door."
He stresses that the Internet is actually a crucial part of the entire scheme, facilitating greater numbers of doctors involvement in AIDS treatment countrywide: "Currently, there is a critical shortage of doctors willing to tackle what they see as the involved treatment of HIV-positive patients. The idea is to establish a central website for patient records. General practitioners anywhere can access these records and follow their patients' progress, and can then contact HIV specialists at the website for specific treatment advice." The model is currently in place and working in this country for diabetics, and Dr. Sanne thinks that it can be practically implemented on a much vaster scale, even in rural areas. "All it takes is one computer and a phone line in a clinic," he says.
In terms of actual treatment regimens, Dr. Sanne is part of the growing cadre of South African doctors who believe that current treatment models, based on American scenarios, may not be applicable to local conditions. "Current US criteria, such as initiating treatment when a patient's CD4 count falls below 500, need a rethink. I believe the trend here will be to rather initiate antiretroviral therapy at a later stage, say around 350, concentrating the treatment on those individuals who are already demonstrating disease progression." Besides reducing the numbers of patients who need therapy, later-stage treatment may also help address government concerns over the long-term toxicity of anti-HIV drugs.
Return to topDr. Sanne in addition firmly supports continued research into the long-term benefits of both nutritional support and herbal remedies in AIDS treatment. "Our proven expertise in South Africa is in the area of clinical research," he points out, "and there have been lots of developments in the phytopharmaceutical arena in particular."
Moducare, a widely used immune-system booster derived from the African potato, is only one such development, resulting from intensive local research into plant sterols and sterolins. Traditional healers in South African rural communities for generations have used the potato as a successful muti (healing compound), prompting immunologists at the University of Stellenbosch near Cape Town to take a closer look. Clinical trials identified two specific compounds, B-Sitosterol and B-Sitosterolin, which exist in all plants and are highly concentrated in the potato. These compounds do not possess antiviral properties in and of themselves, but they demonstrate significant immunomodulatory effects and come at very low cost to the patient.
Further research is also being done on the immune-boosting and nutritional value of herbal and homeopathic remedies. Combined with widespread, cheaper antiretroviral drugs, an affordable and effective treatment regimen may indeed be possible.
Return to topSecure the Future targets South Africa and four of its neighbors – Namibia, Botswana, Swaziland, and Lesotho. The program is examining the vital links in the public health sector that come under continuous criticism. It seeks to examine those areas most needing improvement, such as the training of doctors in HIV treatment, and implement higher ethical standards and good clinical practice. Nongovernment organizations and community service providers are also encouraged to create community-based projects pertinent to HIV/AIDS prevention and care. The most promising projects are put into place for a fixed term and studied for their effectiveness. The program financially supports them on an ongoing basis if they are found to be feasible. "It all ties in," says Dr. Grimwood. "Capacity building and improved infrastructure on all levels lead to improved drug access for everyone."
From a scientific standpoint, his own branch of Secure the Future examines specific research categories of HIV treatment, such as mother-to-child transmission, post-rape cases, and orphan care. Research proposals here are also supported by Secure the Future on the bases of being innovative, sustainable, and replicable. "We are interested in anything which could potentially lead to positive government policy directives," he explains.
Like Dr. Sanne, Dr. Grimwood supports the use of AZT in the South African context, and he hopes that the Secure the Future Program could potentially play an important role in helping to change the government's current view. "Secure the Future facilitates important research," he points out. "The people in power should recognize that negative side effects of AZT can be managed. The research data clearly demonstrate that short-course therapies for expectant mothers have been shown to be relatively low in risk. Considering the realities of our environment, these drugs do offer good options."
Of necessity, the program begins at the urban level, where South Africa's infrastructure and services are most developed. The eventual aim is for it to expand outwards from there. Secure the Future cannot hope to address the government's demands for universal treatment access. In the present early stage, it will not be able to benefit everyone, but only some. It will not, at least in the short term, alleviate the wholesale suffering and death in South Africa's vast rural populations. But since Secure the Future is a privately funded initiative, it does not need government backing or approval to move forward.
"The idea is, you have to start somewhere," says Dr. Grimwood, "Even in a big modern city like Cape Town, we couldn't open all our HIV clinics simultaneously. It would have been impossible. So we started them one by one. It will roll out from there."
For the past decade, Stephen P. Laifer has been an American freelance photojournalist based in Cape Town, South Africa. He regularly reports on health-related news for South African, British, and American publications, and is particularly involved with covering the rapidly developing AIDS pandemic in Africa.
000610
AM000601
Copyright © 2000 by the American Foundation for AIDS Research (amfAR) and first displayed on amfAR's Treatment Directory web site (http://www.amfar.org/gl). They appear on AEGIS with amfAR's permission. Organizations wishing to reprint or redistribute these materials should request authorization from amfAR's Department of Treatment Information Services (212/806-1600).
AEGiS is made possible through unrestricted grants from Boehringer Ingelheim, iMetrikus, Inc., the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 2000. This material is designed to support, not replace, the relationship that exists between you and your doctor.
AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.
Copyright ©1990, 2000. AEGiS & the Sisters of Saint Elizabeth of Hungary. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS and the Sisters of Saint. Elizabeth of Hungary, or the party credited as the provider of the content.