World AIDS Day I

World Aids Day – December 1st, 2011 – a day on which the slogan, “Getting to Zero” is meant to have some resonance. Zero New HIV Infections. Zero Discrimination and Zero AIDS Related Deaths. Let’s have a look at these noble ambitions one at a time in the Zimbabwean context.

World Aids Day – December 1st, 2011 – a day on which the slogan, “Getting to Zero” is meant to have some resonance. Zero New HIV Infections. Zero Discrimination and Zero AIDS Related Deaths. Let’s have a look at these noble ambitions one at a time in the Zimbabwean context.

Start with the last one – zero AIDS related deaths – that would be brilliant for Zimbabwe. It would be quite a journey, because in 2009 (the last year for which figures are available) 83,000 people died from AIDS. There are two ways to stop people dying from AIDS; the more costly, in terms of human and financial resources, is to put them on treatment – anti-retroviral therapy (ART) – for the rest of their lives. The cheaper way to prevent AIDS deaths is to make sure that people don’t catch the virus in the first place. Neither response works alone. Prevention and treatment have to go hand in hand. MSF chooses to concentrate the majority of resources on treatment, because that’s what doctors do best – that’s what we’re here for. So zero AIDS related deaths in Zimbabwe means that, by direct intervention or by advocacy or by system support, we have to double the number of people living with HIV on treatment – and then double the number again. Today there are around 300,000 people in Zimbabwe on treatment and around 1,200,000 people living with HIV, all of whom will eventually need the best treatment available if we’re going to prevent them from dying of AIDS. That’s quite a tough challenge.

Zero discrimination – that should be a little easier – let’s see. At the local level we’re trying to challenge discrimination. One of the best methods is by integration – we no longer run HIV / AIDS facilities as such, we run health facilities where HIV infection is one of the conditions catered for. It’s not easy in a country that has an overall shortage of doctors – the wish to roll out an integrated healthcare system is severely constrained by lack of resources, human and financial. Whilst the stigma has reduced along with the prevalence rate – from 23.7% HIV prevalence in 2001 to 14.3% in 2009 (according to UNAIDS) – restrictive practices remain. The intent is there, but putting national policy into operation is still some years off – an integrated response to HIV remains a distant target. So we strive to eliminate discrimination, but it’s like turning a super tanker – you make the necessary adjustments, but it takes an age for the effect to be seen.  Is discrimination at the local level the only challenge? What about the international response to HIV AIDS – is that inclusive and open and fair, or is it also discriminatory?

We heard with dismay last week that the Global Fund Round 11 was cancelled. The massive leap forward in HIV treatment worldwide that has been delivered by Global Fund projects is mirrored in Zimbabwe. Although MSF funding is separate, we link into a great deal of capacity that is Global Fund initiated or supported. The scale-up that currently sees nearly a third of a million Zimbabweans supported with ART is supported by government, NGO & international institutional funding, the majority of which comes via the Global Fund. So why the reversal of policy? What has happened to the promises? A look at an article by Jeffrey Sachs in the Huffington Post may go some of the way towards explaining it – the reluctance of the US – the largest contributor to the Global fund – to deliver on pledged funding.

Nairobi Hands Off protest

Hands Off protest in Nairobi

"The Obama Administration had pledged $4 billion during 2011-13 to the Global Fund, or $1.33 billion per year. Now it is reneging on this pledge. For a government that spends $1.9 billion every single day on the military ($700 billion each year), Washington's unwillingness to follow through on $1.33 billion for a whole year to save millions of lives is a new depth of cynicism and recklessness.” Where the world’s largest economy leads, the others follow – see this report from the Access Campaign on how the European Union is trying to protect its trading interests via protectionist pressure on India – the manufacturer of choice for most of the HIV drugs used in Zimbabwe.

I characterise the actions of the US and the EU as extremely discriminatory. No doubt there are all sorts of internal political excuses for the US to re-think its funding strategies towards the life-saving objectives of the Global Fund, just as there is going to be justification from the EU for opposing the production of essential affordable drugs in India. But consider this definition: DISCRIMINATION - treatment or consideration of, or making a distinction in favour of or against, a person or thing based on the group, class, or category to which that person or thing belongs rather than on individual merit. Both these decisions are being made, despite promises to the developing world, earnestly made in repeated rounds of high-profile international forums, on the merit of millennium development goals and development assistance targets, because the donor prefers to discriminate against the silent HIV positive majority and in favour of the vociferous few that demand political favour irrespective of morality.

Looking to the third World Aids Day ambition – zero new HIV infections – I wanted a different perspective, so I called on a well-known character in Zimbabwean civil society. Catherine Murombedzi is a journalist for Zimbabwe’s largest selling daily newspaper – The Herald. Catherine is living positively, and writes a regular column about the effects of HIV on Zimbabwean society. So I thought, “An interesting twist – the foreigner asking the journalist for a story – and who better to ask than Catherine.” So I asked her what she thought was the most important message for World Aids Day – she said, “We need to ask ourselves what we are doing to limit the disease. Are we doing enough to prevent the spread of HIV? We know that we can’t afford to treat everybody, because of the failure of donors to deliver on their promises, so increased awareness and advocacy is the affordable option. We can’t afford to think about the implications of the Global Fund decision; we just don’t know what it will mean. I am shocked that world leaders are so easily reneging on their promises. Please – to everyone – we need to do our best to minimise infection – and sustain treatment – our lives depend on it.”

The title of my blog is Positive Thinking because I’m surrounded by remarkable stories of ordinary people all linked together in Zimbabwe by their shared experiences around the HIV AIDS pandemic. I’m struggling to find the positive in this post, but it’s there. In amongst all the international funding idiocy, the bad politics and the broken promises, there are glimmers of hope. The ordinary people of Zimbabwe, so many of them living with HIV, get up and take their tablets and take their kids to school and attend the health clinic – for now – supported by the complex mechanisms that convert cash from the world’s richest countries into life-saving drugs and health messages here in Zimbabwe.  I’m positive because MSF continues to bring some sanity to this international circus. I’m positive because stupid political decisions are always reversible – we can lobby and blog and celebrate the positive lives of our patients in the expectation that sanity will prevail. It’s our moral duty. After all, governments are short-lived, but HIV is for life.