AFRO-NETS> Kaiser Daily HIV/AIDS Report - Tue, 13 Nov 2001

[Cecilia Snyder <csnyder@ccmc.org>]

Kaiser Daily HIV/AIDS Report - Tue, 13 Nov 2001
-----------------------------------------------

* Rolling Stone Investigative Report Examines the Accuracy of AIDS
  Statistics in Sub-Saharan Africa
* WTO Ministers to Vote on TRIPS Compromise That Allows Developing
  Nations to Override Patents in Public Health Crises
* Zambian Women Prefer Nevirapine Therapy Without HIV Testing to Pre-
  vent Perinatal Transmission When Resources Are Limited

--
Rolling Stone Investigative Report Examines the Accuracy of AIDS Sta-
tistics in Sub-Saharan Africa

In the Nov. 22 issue of Rolling Stone, South African journalist Rian 
Malan investigates why different organizations have different HIV/ 
AIDS statistics for South Africa and other sub-Saharan African coun-
tries. In July of last year -- three months after South African 
President Thabo Mbeki convened a panel to re-examine the relationship 
between HIV and AIDS -- Malan began his investigation into Africa's 
AIDS statistics. He, like Mbeki, began his search for information on 
the Internet. At the time, Malan found that according to the World 
Health Organization and UNAIDS, an estimated 22 million Africans were 
HIV-positive and 14 million additional people had died of AIDS-
related complications. Through interviews with WHO and UNAIDS offi-
cials, Malan discovered that these statistics were not based on ac-
tual case reporting, as the numbers are in the West, where "[a]lmost 
every new AIDS case is scientifically verified and reported to gov-
ernment health authorities" who report their totals to WHO officials 
in Geneva, Switzerland. Instead, HIV/AIDS statistics for African na-
tions are primarily derived by testing pregnant women at government-
sponsored prenatal clinics. According to UNAIDS, blood is drawn for 
syphilis testing and then once a year, blood left over from the 
syphilis tests is collected and tested for HIV. The results are then 
"fed into a computer model that uses 'simple back-calculation proce-
dures' and knowledge of 'the well-known natural course of HIV infec-
tion' to produce statistics for the continent." 

Comparing South Africa

Public health officials can "theorize at will about the rest of Af-
rica," but South Africa is a "semi-industrialized nation with a re-
spectable statistical service," Malan writes. Although "coverage is 
far from complete," Ian Timaeus of the London School of Hygiene and 
Tropical Medicine and a UNAIDS consultant said, "South Africa is the 
only country in sub-Saharan Africa where sufficient deaths are rou-
tinely registered to attempt to produce national estimates of mortal-
ity from this source." Eighty percent of deaths are registered in 
South Africa compared to 1% in the rest of sub-Saharan Africa. Ac-
cording to the WHO model that tests pregnant women, AIDS-related 
deaths have tripled in South Africa over three years, from approxi-
mately 80,000 deaths in 1996 to 250,000 deaths in 1999. But when Ma-
lan compared the increase in deaths with the number of registered 
South African deaths for those years, he found "no such" increase, as 
registered deaths increased from 294,703 to 343,535 over the same 
time period. He contacted Statistics SA, the government's census 
agency, to verify the numbers and was told that they were correct. 

WHO Is Correct?

Confused by the discrepancy in the numbers, Malan examined other 
population-based surveys in an attempt to discern sub-Saharan Af-
rica's real HIV/AIDS figures. But the numbers gained through field 
research and those collected by national agencies failed to add up, 
so Malan began to question the validity of WHO's predictions. He 
notes that gross overestimates of the extent of the AIDS epidemic in 
the United States were made in the 1980s and early 1990s. In 1985, 
the CDC said that 1.5 million Americans were already infected with 
HIV and that two to three million would be infected within 10 years. 
However, a 1997 analysis found that only 450,000 people were infected 
in the mid-1980s. "If the numbers could be gotten so wrong in Amer-
ica, what are we to make of the infinitely more dire death spells 
cast upon the developing world?" Malan asks. 

Testing Discrepancies

One reason for WHO's inflated HIV/AIDS estimates may be the type of 
HIV testing being done in sub-Saharan Africa, Malan theorizes. Unlike 
Western countries, which use two primary tests (ELISA tests) and a 
confirmatory test for HIV, the standard protocol in developing coun-
tries is one ELISA test, which means "almost nothing" in the United 
States, Malan notes. In addition, he says that false-positive test 
results are more common in sub-Saharan Africa due to the presence of 
plasmodium falciparum, a parasite that causes malaria, in many peo-
ple. But Malan wonders why, if there may be so many false positives, 
governments do not take stronger measures to ensure accurate testing. 

More Money

Higher HIV rates mean more money from foreign aid groups and other 
governments, which currently spend about $1 billion a year in AIDS-
related funding, Malan says. The money also "translate[s] into pa-
tronage for politicians and good jobs for their struggling constitu-
ents," he adds. Still, UNAIDS' chief epidemiologist Dr. Bernhard 
Schwartlaender said that the agency's computer model, which is the 
same as the one used by WHO, is "completely dependable." He acknowl-
edged that the model is just an estimate and over time the curves for 
the model and the recorded death rate will coincide. "The models may 
completely disagree at a particular point in time, but in the end the 
curves look incredibly similar. They're goddamn consistent," Schwart-
laender said. However, Malan remains unconvinced and confused. "Are 
these numbers right?" he asks. "Who knows," he answers, adding that 
the "entire quest has driven me ... mad" (Malan, Rolling Stone, 
11/22).


--
WTO Ministers to Vote on TRIPS Compromise That Allows Developing Na-
tions to Override Patents in Public Health Crises

A World Trade Organization ministerial working group meeting in Doha, 
Qatar, is expected to approve today text that would allow WTO member 
nations to use the flexibility of the Trade-Related Aspects of Inter-
national Property Rights (TRIPS) agreement to "ensure access to medi-
cines for all," BBC News reports (Schifferes, BBC News, 11/13). Yes-
terday, WTO negotiators "all but clinched a deal" on the draft, which 
"assure[s] developing countries that patent rules do not stand in the 
way of producing or importing generic drugs when they face epidemic 
health crises like AIDS and malaria," the New York Times reports 
(Kahn, New York Times, 11/13). In addition, the draft also gives the 
poorest countries a 10-year delay on the implementation of patent 
laws on medicines and allows all countries the right to decide under 
what circumstances they can override the patents of pharmaceutical 
companies during public health crises (Winestock/Cooper, Wall Street 
Journal, 11/13). The text is expected to state that TRIPS "can and 
should be interpreted and implemented in a manner supportive of WTO 
members' rights to protect public health and in particular to ensure 
access to medicines for all" (BBC News, 11/13). However, the text re-
fers the issue of parallel importation, in which countries can import 
generic versions of patented drugs, to a committee (Wall Street Jour-
nal, 11/13). India and Brazil, two countries that have lobbied to 
loosen restrictions on patents for medicines, "appeared satisfied" by 
the draft (New York Times, 11/13). Ministers are expected to formally 
approve the text later today (BBC News, 11/13).

Brokering a Deal

The United States, which had initially opposed a proposal by 52 de-
veloping nations regarding TRIPS language, was "instrumental" in de-
veloping the compromise. A U.S. trade official said that the United 
States believed that settling the dispute over medicines and patents 
was "necessary to 'create a positive dynamic'" at the meeting and to 
spur talks on other trade issues (New York Times, 11/13). The Wall 
Street Journal reports that the draft "shows how far the [WTO] has 
come" on the issue of patent protection for medicines. Jamie Love, 
director of the Consumer Project on Technology, said, "Two years ago, 
you never could have got anything like this in the WTO. This is way 
better than what was floated in Seattle" (Wall Street Journal, 
11/13). Ian Bray of Oxfam added that the agreement is "better than 
anyone could have hoped for a year ago," but added that his group is 
"disappoint[ed]" that there has been no agreement on the issue of ge-
neric importation (BBC News, 11/13). Asia Russell of the Health GAP 
Coalition said, "This is far from a 100% victory. But it leaves the 
door open to further discussion, debate and pressure" (Reuters/ Bal-
timore Sun, 11/13). The pharmaceutical industry, however, "hit the 
roof" after learning of the text's contents (Dougherty, Washington 
Times, 11/13). Harvey Bale, a lobbyist for the International Federa-
tion of Pharmaceutical Manufacturers Associations, said, "This is a 
defeat for drug companies doing research in AIDS, tuberculosis and 
the like" (New York Times, 11/13). Bale said that developing a new 
AIDS drug can cost $1 billion, and that weaker patent protection will 
"kill incentives for research" into AIDS and other "controversial" 
diseases (Washington Times, 11/13).


--
Zambian Women Prefer Nevirapine Therapy Without HIV Testing to Pre-
vent Perinatal Transmission When Resources Are Limited

Universally providing the antiretroviral nevirapine to pregnant women 
without testing for HIV -- a strategy known as mass therapy and used 
to prevent vertical HIV transmission in high-risk areas with very 
limited resources -- is "controversial," but most Zambian women said 
in a survey that they would prefer the method, according to a study 
published in the Nov. 10 issue of the Lancet. Mass therapy has been 
found to be more cost-effective and preferable in regions that lack 
trained clinical staff, health care infrastructure and resources to 
test and counsel patients than the more standard targeted therapy, in 
which patients receive the drug only after testing positive for HIV. 

Mass vs. Targeted

To survey the preferences of the women who would be eligible to re-
ceive mass nevirapine therapy, Moses Sinkala of the Zambian Ministry 
of Health and colleagues gave a questionnaire to 310 Zambian women at 
two public antenatal clinics in Lusaka following an educational ses-
sion on HIV and nevirapine. The women were asked which treatment ap-
proach -- mass vs. targeted -- they would choose if resources were 
available to test and provide nevirapine to all patients, and which 
they would choose if resources were limited. The survey showed that 
when presented with a setting of unlimited resources, 74% of women 
preferred targeted therapy, saying they would prefer to be tested for 
HIV and then given the drug only if found to be infected. Twenty-
three percent said they did not wish to know their HIV status, but 
just wanted to be given the drug, and 2.3% said they did not wish to 
be tested or given nevirapine. In a setting without the resources to 
test and treat everyone, in which only 50% of patients could be both 
tested and treated, 60% of the women said they would prefer mass 
therapy, and 39% said they would prefer that testing and nevirapine 
be offered to half of the women and nothing to the other half. Women 
who described their personal HIV risk to be moderate or high were 
"significantly" more likely to choose mass therapy for themselves, 
but not more likely to advocate it as general policy under a limited 
resource setting. The researchers noted, "Given the recent commitment 
by the manufacturer (Boehringer Ingelheim) to donate nevirapine 
throughout the less-developed world, there will be continued pressure 
to consider mass administration. ... This survey suggests that most 
women in Lusaka would support a mass therapy approach if it would al-
low a greater proportion of women to receive nevirapine" (Sinkala et 
al., Lancet 11/10).

--
The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org, 
a free service of The Henry J. Kaiser Family Foundation, by National 
Journal Group Inc. c 2001 by National Journal Group Inc. and Kaiser 
Family Foundation. All rights reserved.

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