A Tentative (Mixed) Public Health Victory: The Slow Retrenchment of HIV-AIDS

This is from the Economist, on the state of the fight against HIV-AIDS.

The next UN target is that, by 2020, 90% of those infected should have been diagnosed and know their status, 90% of those so diagnosed should be on ARVs, and 90% of those on ARVs should have suppressed viral loads. That is ambitious, but history suggests those in the field will rise to the challenge.

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The blue line is testament to George W. Bush’s No. 1 foreign policy success: PEPFAR.

But we should count our chickens just yet. The trends in the graph above are not uniform across the globe. As I noted in a previous post, there is quite a bit of heterogeneity both across and within countries. For example, in East Africa, Uganda is lagging Kenya and Tanzania in the quest to tame the virus (see below).

On a different note, this is yet another data point to suggest that Yoweri Museveni has hit the inflection point, and from now on all his machinations to stay in power will wipe out the achievements of his first 20 years in power.

The Continuing Deterioration of Uganda Under Museveni: The Case of HIV & AIDS

In the 1990s Uganda was typically considered to be one of the success stories in the management of the AIDS epidemic in SSA. However, as is shown below, since the early 2000s Uganda has significantly lagged its regional peers (Kenya and Tanzania) in the fight against HIV/AIDS. New infections are declining in Kenya and Tanzania but increasing in Uganda. HIV prevalence also appears to be increasing in Uganda, while either declining or keeping steady in Tanzania and Kenya. Lastly, of the three countries, the rate of decline in AIDS-related deaths has been slowest in Uganda.

It’s not clear to me why the HIV/AIDS situation has deteriorated in Uganda since the late 1990s relative to its neighbors. After all, the three countries have been receiving cash from PEPFAR since 2004 (which explains the decline in AIDS related mortality in the mid-2000s after the use of ARTs became widespread).

My hunch is that this is a reflection of Yoweri Museveni’s gradual loss of control of the state institutions that he has worked hard to build since 1986. It is also probably related to the manner in which Museveni chose to deal with the advent of competitive politics in Uganda after the end of the no-party “movement” era. His strategy has come to be defined by a willingness to basically buy off anyone and everyone — at the expense of state institutions and specific government agencies.

Consider this:

The OIG auditors identified stock-outs of key medicines, particularly those to treat HIV, in 70% of 50 health facilities visited which could result in treatment disruption for patients. Furthermore, 54% of the health facilities visited had accumulated expired medicines. 68% of facilities reported stock-outs of anti-malaria medicines and test kits and 64% of the facilities reported stock-outs of tuberculosis medicines of between one week and three months.

The OIG concluded that the supply chain system does not effectively distribute and account for medicines financed by the Global Fund. There were reported cases of theft, including 40 cartons of artemisinin-based combination therapies; an unexplained difference of US$21.4 million between recorded and actual stocks at the central warehouse; and a difference of US$1.9 million between commodities received and actually dispensed to patients from January 2014 to June 2015 in eight high-volume facilities visited by the auditors.

Screen Shot 2016-03-05 at 9.20.11 AMUganda’s post civil war economic recovery may have been impressive (see graph), but it should no longer be something for Museveni to hang his hat on. It is clear that the longer Museveni stays in office, the more he is going to undo his very own achievements in the earlier years of his three-decade rule.

 

 

UN reports gains in the global fight against AIDS

There is more good news in the area of public health. A couple of days ago I posted on the decline of human mortality rates in the tropics. Now the UN agency for HIV/AIDS, UNAIDS, reports that HIV infection rates, especially of the mother-to-child variety, are on a downward trend.

The New York Times reports:

New infections with H.I.V. have dropped by half in the past decade in 25 poor and middle-income countries, many of them in Africa, the continent hardest hit by AIDS, the United Nations said Tuesday.

The greatest success has been in preventing mothers from infecting their babies, but focusing testing and treatment on high-risk groups like gay men, prostitutes and drug addicts has also paid dividends, said Michel Sidibé, the executive director of the agency U.N.AIDS.

Adding that:

Some regions, like Southern Africa and the Caribbean, are doing particularly well, while others, like Eastern Europe, Central Asia and the Middle East, are not. Globally, new infections are down 22 percent from 2001, when there were 3.2 million. Among newborns, they fell 40 percent, to 330,000 from 550,000.

Life expectancy in Kenya jumps to 64

The Daily Nation reports:

The life expectancy of a Kenyan has increased to 64 years up from 55 two years ago, a report released on Sunday shows.

The data compiled by the University of Nairobi in partnership with 12 other universities worldwide notes that the life of Kenyans has improved substantially and they can expect to live longer.

The report, State Of The Tropics, further says that Zimbabwe is the only nation in the world that recorded a decline in life expectancy at 47 years.

Madagascar reported the largest improvement in life expectancy to 65.8 years, with large reductions in infant and adult mortality rates.

…. In regional terms, Zimbabwe has a low infant mortality rate, but a very high adult mortality rate (the highest in the world)

Overall, there has been massive improvement in life expectancy in the tropics since the fifties:

…. life expectancy in the tropics has increased by 22.8 years to 64.4 years between 1950 and 2010 and the gap between the life expectancy of women and men has widened in favour of women over the same period.

I guess this calls for an investigation of the real causes of the drop (if the data hold up) in mortality rates (especially infant mortality). Is it better healthcare, diet or just a natural secular trend? Or could it be better economic prospects (since the mid-1990s) that inspire greater investment in healthcare? Also, has the AIDS epidemic peaked in the tropics? Over to you, epidemiologists.

It is a bit odd that a country like Zimbabwe has a low infant mortality rate but a high adult mortality rate – why has the total collapse of state institutions disproportionately affected health provision to adults?

The Catholic Church and AIDS: A Sorry Case of Denial

The Church’s continued ostrich approach to the catastrophe that is HIV/AIDS on the continent:

Pope Benedict XVI on Saturday signed off on an African roadmap for the Roman Catholic Church that calls for good governance and denounces abuses, while labelling AIDS a mainly ethical problem. Benedict signed the apostolic exhortation called “The Pledge for Africa” during a visit to the West African nation of Benin, his second trip to the continent as pontiff.

The document says AIDS requires a medical response, but is mainly an ethical problem.

Changes in behaviour are required to combat the disease, including sexual abstinence and rejection of promiscuity, it adds. “The problem of AIDS in particular clearly calls for a medical and a pharmaceutical response,” it says. “This is not enough however. The problem goes deeper. Above all, it is an ethical problem.”

More on this from the Daily Nation.

I have written against the Church’s policy on birth control here, here and here.

More good news on the fight against AIDS

AIDS researchers, many of whom have been meeting this week in Rome under the auspices of the International AIDS Society, are rightly pleased with the progress they have made. In particular, the use of antiretroviral drugs has not only revolutionised treatment of HIV infection, but also offers the prospect of stopping the spread of the virus. In a matter of weeks, these drugs reduce the number of viruses per millilitre of infected blood from millions to less than 50. That deals with both symptoms and infectivity. Unless a patient stops taking the drugs, or goes on to develop resistance to them, he can expect to live almost as long as an uninfected individual.

……. there is a glimmer of hope on the horizon. To deal with dormant viruses several researchers are taking what sounds like a counterintuitive approach. They are trying to wake the viruses up and so boost, rather than reduce, the amount of active HIV in a patient’s body. Their reasoning is that the now-active viruses will either kill the cells they are in (and thus themselves) or encourage the immune system to attack those cells.

That is the Economist in its latest issue. For more on the details of the state of AIDS research go here.

The Economist’s optimism is supported by empirical data. According to the Vancouver Sun:

HIV patients in Uganda who are receiving regular treatment can expect to live a near-normal lifespan, Canadian researchers have suggested in the world’s first large-scale study to examine HIV patients’ life expectancy in Africa.

After studying 22,315 patients who were using combined antiretroviral therapy (cART), scientists from the B.C. Centre for Excellence in HIV/AIDS along with experts at the Universities of British Columbia and Ottawa found that with early initiation and access to regular treatment, those infected with HIV were living about two-thirds of a normal lifespan.

More on this here.

 

Can the fight against aids be won?

There is hope that the fight against AIDS can be won.

Over the last 30 years the disease has killed millions and created millions of orphans.

It’s lasting impact persists in lost human capital and reduced labor productivity (see paper on this here). But if the optimism of the Economist (and they are not known for their love of the bright side of things) is anything to go by, things might be changing for the better.

The 30th anniversary of the disease’s discovery has been taken by many as an occasion for hand-wringing. Yet the war on AIDS is going far better than anyone dared hope. A decade ago, half of the people in several southern African countries were expected to die of AIDS. Now, the death rate is dropping. In 2005 the disease killed 2.1m people. In 2009, the most recent year for which data are available, the number was 1.8m. Some 5m lives have already been saved by drug treatment. In 33 of the worst-affected countries the rate of new infections is down by 25% or more from its peak.

Even more hopeful is a recent study which suggests that the drugs used to treat AIDS may also stop its transmission (see article). If that proves true, the drugs could achieve much of what a vaccine would. The question for the world will no longer be whether it can wipe out the plague, but whether it is prepared to pay the price.

More on this here.

mbeki’s legacy

Partial results of Thabo Mbeki’s beetroot response to the South African AIDS epidemic are out. Life expectancy in South Africa declined between 1990-2007 (from 62 to 50). It is expected to decline even further over the next few years. Read more about this here.

It is worth noting that the new South African administration took an about-turn from Mbeki’s bizarre AIDS policy, as was articulated by his health minister. The South African Ministry of Health has on its website an HIV and AIDS and STI strategic plan designed to tackle the HIV problem. Over 5 million South Africans, out of a total population of 49.3 million, are infected.

i still don’t get how the church justifies this

The Catholic Church, among other churches, continues to be opposed to birth control measures that also help in the prevention of AIDS. This is such a disappointment. Millions of people have died from the disease since its emergence in the 1980s. Currently there are more than 20 million infected people on the Continent, and 11 million orphans as a result of HIV-related deaths. Clearly this is a situation that calls for a rethink of the Church’s policy on the use of condoms.

This is separate from the abortion debate. This is about disease prevention. I find it hard to reconcile church teachings of love with the heartless condemnation of millions to their graves. Now, individuals can make their own decisions regarding whether to engage in unprotected sex or not. But I also think that it matters if their priest or pastor tells them to do so. As long as the church is against AIDS prevention (yes, refusal to allow condom use amounts to being against AIDS prevention) government efforts to tame the disease will continue to founder.

It is easy for moralists perched up in far off places to dictate to their faithfuls on the Continent that they should not use birth control or protect themselves against AIDS. But African governments should know better than to stand by and let this be. They are the ones who are losing hundreds of thousands of teachers, doctors, engineers, civil servants and most importantly PARENTS every year. Millions of children are left orphaned and therefore a burden to the state. Rome or the evangelical churches will never have to deal with the losses that these governments have to deal with as a result.

There is a huge disconnect between the church and the realities on the ground on the Continent. The fact of the matter is that people are having sex outside of wedlock. The church (and even the state) should have good reasons to worry about this (the concern here being the hordes of unplanned pregnancies, especially among teenagers). But the best way to deal with it is not to preach abstinence and then pretend that people will listen. Governments and the church should be aggressive with ALL preventive measures. Once the disease is down to negligible levels then perhaps we can revive the moralizing crusades. Now is simply not the time.

africa still remains the land of disease, not investment

I am a fan of Business Week magazine. I like the magazine’s short but informative pieces on the state of the world’s economy, especially in these harsh economic times. However, being an ardent Africanist, I am often disappointed by how little coverage there is of the Continent in the magazine. This week’s piece had articles mostly from the US, Europe and Asia – with a few mentions of Latin America, notably Brazil. Africa was nowhere to be seen in terms of investment or economic performance. And this is not just the case with BW. Africa is still largely irrelevant when it comes to global economics – irrelevant in the sense that, with the exception of South Africa, it remains a passive player, being a mere source of raw materials for other regions of the world.

I wonder if anyone in the Continent’s state houses reads any of these international publications. I wonder how many of them look at The Economist’s Middle East and Africa section and hit their heads against the wall thereafter. May be they do, but just don’t give a rat’s behind or don’t know how to begin tackling their nations’ many problems. These are the same clowns who oftentimes complain about the Continent’s negative press. While I agree with them to a point, I think most of the negative press that the Continent gets is well deserved. It is true that way too many African children die before they are five. It is true that most of Africa is still in the 16th century. It is also true that most African leaders are visionless kleptocrats. And most importantly, it is true that Africa remains poor and, objectively speaking, backward not because of her people’s shortcomings but because of poor leadership. Where there is good leadership – like in Botswana and more recently in Mozambique and Tanzanaia – we have seen good things happen.

The Continent has to stop being a spectator in global politico-economic issues. But this will only happen if its leaders take their jobs more seriously. Less sleaze and arbitrary government will definitely help.