AFRICANEWS

Africa/United States

AIDS Prevention Not Treatment: Why Natsios Is Wrong

AIDS

The new United States' Agency for International Development (USAID) boss Andrew Natsios caused an uproar last month by his racist assessment that Africans should not receive AIDS drugs because they can't tell time and would therefore not stick to the strict schedules of antiretrovirals. But it seems that Natsios didn't do his homework according to a survey conducted by a medical AIDS body in the US.

The new AIDS policy for Africa set out by the United States' Agency for International Development (USAID) seeks only to prevent the spread of HIV/AIDS and allocates little, if any, money for treatment that would prolong the lives of people living with HIV/AIDS. The policy, thus, withholds funding for the administration and use of highly active antiretroviral therapy (HAART) that would bring relief to millions of HIV-positive Africans.

Andrew Natsios, the new USAID Administrator, stated this policy in testimony for his confirmation hearings April 25. In a June 7 interview with Boston Globe, Natsios justified the decision to withhold treatment by claiming that the regimens for taking the drugs are too difficult for Africans to adhere to and, thus, there is no point in attempting to administer them.

Natsios went so far as to state that Africans "don't know what Western time is. You have to take these (AIDS) drugs a certain number of hours each day, or they don't work. Many people in Africa have never seen a clock or a watch their entire lives. And if you say, one o'clock in the afternoon, they do not know what you are talking about. They know morning, they know noon, they know evening, they know the darkness at night. I'm sorry to be saying these things, but a lot of people advocating these things have never worked in health care in rural areas in Africa or even in the cities."

In refusing to offer the relief, Natsios reverted to attacking the victim, a ploy that raised uproar in the world press. So far, however, under his direction the USAID is adhering to its policy of the denial of treatment.

There is no question that HAART therapy prolongs life. Studies published in the New England Journal of Medicine (1998), Lancet (1998), and the Journal of Infectious Diseases (1999) showed that the therapy has resulted in "substantial reductions in HIV-related morbidity and mortality." The Guidelines for the Use of Antiretroviral Agents in HIV-Infected Adults and Adolescents, published April 23 of this year by the U.S. Department of Health and Human Services (DHHS), set out the administration of HAART to Americans. The guidelines say that: "Results of therapy are evaluated primarily with plasma HIV RNA levels; these are expected to show� no detectable virus at four to six months after initiation of treatment." The Panel on Clinical Practices for the Treatment of HIV, which brought together more than 100 experts in the field, developed the DHHS Guidelines for HAART.

By emphasizing "prevention" at the expense of treatment, Natsios is unequivocal that the prolongation of African life is not a concern for his agency. Overlooked is the fact that the longer those infected with HIV are able to live and regain health, the longer they are able to hold jobs, support their families, and prevent their children from joining the growing ranks of millions of African "AIDS orphans." How important is it to a child of an HIV-infected person and to the growth and development of that child that their mother or father continues to live, or dies?

Aside from its callous disregard for human life, the USAID policy is also incompetent on several counts. First, treatment is prevention. The DHHS Guidelines state, "potential benefits of early therapy include earlier suppression of viral replication; preservation of immune function; prolongation of disease-free survival; and decrease in the risk of viral transmission." This is true not only for physiological, but also for social and psychological, reasons. When the government of Botswana launched its national HAART program for people with HIV/AIDS, many people - who otherwise would have been too afraid or disheartened - came out to be tested for HIV, according to The New York Times.

The Times quoted one doctor in Botswana as saying that the program "will bring forward more people for testing; it destigmatises the whole pandemic." Said another medical administrator: "Two years ago, if you asked employees to get tested, they would say 'What for? Why should I know if I'm dying if there's no cure?' Now we have an answer."

The DHHS panel notes that adherence to the drug regimen "is essential for successful treatment." The drugs must be taken on schedule two or more times a day, every day. According to a study published last year in the Annals of Internal Medicine, 90 to 95 percent of the doses must be taken for optimal suppression. The Guidelines state that, conversely, "poor adherence has been shown to increase the likelihood of virologic failure and has been associated with morbidity and mortality."

Poor adherence to the drugs may also raise new dangers, as it leads to the development of drug-resistant strains of HIV.

While Natsios is not wrong to point out the difficulties of adhering to a strict medical regimen, he is way off the mark in ascribing such problems to Africans alone. According to the DHHS Guidelines, cited as an authority by the Centres for Disease Control in Atlanta, "imperfect adherence is common" in the United States!

"Surveys have shown that one-third of patients missed doses within three days of the survey," says the DHHS Guidelines. "One fifth of HIV-infected patients in one urban centre never filled their prescriptions."

The Guidelines for American HIV Patients take an approach completely opposite to Natsios's view that Africans have particular problems adhering to a regimen. It states: "Clinicians are reminded that such factors as gender, race, socio-economic status, educational level, and past history of drug use do not reliably predict poor adherence. Conversely, a higher socio-economic status and educational levels and a lack of history of drug abuse do not predict adequate adherence [according to a study published in the 1998 Journal of the American Medical Association]. No individual patient should automatically be excluded from consideration from antiretroviral therapy simply because he or she exhibits a behaviour or other characteristics judged by some to lend itself to non-adherence."

Natsios, however, was correct in identifying obstacles to the effective delivery of all medical care in Africa due to the total collapse of services and infrastructure throughout the continent. People "do not know the challenges we have with diseases that we have cures for," he told The Boston Globe. "We cannot get it done because of conflicts, because of lack of infrastructure, lack of doctors, lack of hospitals, lack of clinics, lack of electricity."

However, this is no reason to deny treatment to people living with HIV/AIDS in Africa. The lack of medical and physical infrastructure in Africa is one result of the neo-colonialist rule of the International Monetary Fund, and requires urgent action on the debt, the lifting of conditionalities, and aid to rebuild infrastructure. Natsios's attitude, however, perpetuates the neo-colonialist policies toward Africa that created the conditions for HIV/AIDS to course its way throughout the population without restraint.

The DHHS Guidelines Summary plainly states the U.S. government's policy for HIV patients in the United States: "With regard to specific recommendations, treatment should be offered to all patients with the acute HIV syndrome, those within six months of HIV seroconversion, and all patients with symptoms ascribed to HIV infection." HIV patients in Africa should receive the same.

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