The 1990s – Southern Africa and the Fight for Treatment

The beginning half of the 1990s was a bleak time in the history of AIDS in Africa. At a time when new HIV infection rates were rocketing in Southern Africa there were few new ideas of how to deal with generalised epidemics in poor countries¹. Prevention campaigns were having minimal effect and there was no visible prospect for effective treatment in Africa. The international community was yet to take efficient action and many national government programmes were corrupt or ill-equipped to deal with the escalating crisis². By the middle of the decade the seriousness of the epidemic was blatant. In 1999, the Kenyan President Daniel Arap Moi declared AIDS a national disaster.

"AIDS is not just a serious threat to our social and economic development, it is a real threat to our very existence, and every effort must be made to bring the problem under control." ³

Although HIV/AIDS prevalence continued to increase in Southern Africa in the later Nineties, glimmers of hope for the future of the epidemic began to emerge.
Prevalence rates in many East African countries that were hard hit in the 1980s were beginning to slow, stabilise or decline. Between 1992 and 1998 prevalence rates in Uganda were estimated to have dropped from 30% to 12% of adults in Kampala⁴.
In 1996, UNAIDS was established to take responsibility for coordinating international action against the epidemic^{5 6}.

Rocketing prevalence rates in sub-Saharan Africa

Sub-Saharan Africa was the hub of the HIV epidemic of the 1990s. In 1993 there were an estimated 9 million people infected in the sub-Saharan region out of a global total of 14 million⁷.
In 1998 sub-Saharan Africa was home to 70% of people who became infected with HIV during the year, with an estimated one in seven of these new infections occurring in South Africa⁸.

HIV epidemic in Sub-Saharan Africa, 1995-2000.

As HIV/AIDS entered the southern African countries with force, those infected faced high levels of stigma. In 1998, Gugu Dlamini, a South African AIDS activist, was beaten to death by her neighbours after revealing her HIV positive status on Zulu television. This happened just a month after Deputy President Thabo Mbeki had called for people to ‘break the silence about AIDS’ in order to defeat the epidemic⁹.
South Africa had reacted slowly to the emerging epidemic. The ANC had replaced the apartheid government in 1994 and had concentrated on unifying the country’s health systems and expanding primary health care for the poor. This restructuring weakened the health systems just as the HIV/AIDS epidemic was at the peak of expansion. In 1998 the health ministry stopped trials of AZT to prevent mother-to-child-transmission claiming that it was too expensive and that it would focus its funds on other prevention campaigns. This provoked the first major political action by HIV positive Africans over their own treatment¹⁰.
The ANC did not work with AIDS organisations and tension between the party and AIDS activists escalated throughout the decade. Due to an increasing frustration with the governments inefficient action against AIDS, in 1998 the Treatment Action Campaign (TAC) was founded. Led by Zackie Achmat this group was to become important in the fight for treatment in South Africa.¹¹.

The Fight for Treatment

In 1996 the effective combination therapy known as HAART became available for those living with HIV in rich countries. The new drugs were so effective that AIDS death rates in developed countries dropped by 84% over the next four years¹². This led scientists to declare, ‘aggressive treatment with multiple drugs can convert deadly AIDS into a chronic, manageable disorder like diabetes’¹³.
However, as the South African Health Minister, Nkosazana Zuma, pointed out,

"most people infected with HIV live in Africa, where therapies involving combinations of expensive antiviral drugs are out of the question" - ¹⁴.

At a cost of $10,000-15,000 per person per year it would cost sub-Saharan countries between 9% and 67% of their GDP to provide triple combination therapy to everybody living with HIV in their countries¹⁵.
This was clearly impossible for the majority of African nations and the disparity in treatment options angered many people for whom treatment was too expensive. South Africa began to lobby the multi-billion-dollar pharmaceutical corporations of the West to either allow local companies to manufacture HIV/AIDS drugs themselves (this is called compulsory licensing) or import them from other countries, that were producing generic (or copied) drugs at a low cost (this is called parallel importing)¹⁶.
The drug companies argued that if their patents were not protected, there would not be the incentive to do the research and development necessary to continue the fight against AIDS¹⁷, and they fought vigorously to protect their privileges. The US sided with the pharmaceutical companies and threatened tough sanctions against South Africa¹⁸.
Eventually, in December 1999 the US and the pharmaceutical companies backed down and Bill Clinton announced that the United States would exercise flexibility in the enforcement of drug patent laws when countries face a public health crisis¹⁹. The United States approved local production or importation of cheap HIV drugs in South Africa as long as the imported drugs had intellectual property right protection²⁰.
This was an initial victory for the fight for treatment in resource poor countries but did not signal an immediate roll out of drugs for those living with AIDS in Africa. For a start not every country had the industry to manufacture drugs locally, or the money to import the drugs, even at a lower cost.
Additionally, this treatment was demanding of clinical services and many governments did not have the healthcare infrastructure to manage large-scale treatment programmes. In the 1980-90s, sub-Saharan Africa had the world’s lowest level of social security cover, which includes doctor/patient ratio and access to health services²¹.
In other medical advances in 1994 it was discovered that AZT could reduce mother-to-child-transmission by two-thirds²². Although this transformed transmission through pregnancy in developed countries, the cost of about $1,000 per case was prohibitive for those in poor countries. After trials in Thailand showed that a shorter course of AZT also helped to prevent mother-to-child transmission of HIV²³, the drug company Glaxo Wellcome cut the price of AZT by 75% in 1998. Peter Piot, director of UNAIDS, praised the ‘hope factor’ of the drug and in 1999 Botswana launched Africa’s first programme to combat mother-to-child transmission.

References

1. Iliffe, J (2006) ‘The African AIDS epidemic: A History’ James Currey. Oxford.  Pg. 140
2. Iliffe, J (2006) ‘The African AIDS epidemic: A History’ James Currey. Oxford.  Pg. 126
3. Agence France-Presse (1999) 'AIDS a national disaster but condoms not answer: Kenya's MOI', November 26
4. Mayanja V. (1999) 'Openness about HIV/AIDS slows infection rate in Uganda', Agence France Press, September 8
5. Bureau of Hygiene & Tropical Diseases (1994) 'AIDS newsletter' Vol.9 (11), August
6. Iliffe, J (2006) ‘The African AIDS epidemic: A History’ James Currey. Oxford.  Pg. 138
7. WHO (1995) 'Global Programme on AIDS, progress report 1992-1993', p.2
8. UNAIDS (1998) 'AIDS epidemic update', December
9. The Associated Press (1998) ‘HIV Positive SAfrica Woman Murdered’, December 28
10. Iliffe, J (2006) ‘The African AIDS epidemic: A History’ James Currey. Oxford.  Pg. 143
11. Iliffe, J (2006) ‘The African AIDS epidemic: A History’ James Currey. Oxford.  Pg. 143
12. The Lancet (2003) 'Determinants of survival following HIV-1 seroceonversion after the introduction of HAART', Vol. 362
13. The Los Angeles Times (1996) 'Studies of combined HIV drugs promising; Health: experts at AIDS conference unveil early results showing treatment involving certain medications reduces virus to undetectable levels', July 12
14. Brown D. (1996) 'With fanfare, Global AIDS Conference gets underway in Vancouver', the Washington Post, July 8
15. UNAIDS, 1997 figures in BBC News: The drugs companies
16. BBC News (1999) 'Africa AIDS drug trade dispute ends', September 18
17. BBC News (2003) ‘HIV Drugs: You asked our panel’ November 21
18. UNAIDS, 1997 figures in BBC News: The drugs companies
19. SFGate (1999) ‘Poor nations given hope on AIDS drugs. New policy would lower prices’ December 3
20. BBC News (1999) ‘World: Africa AIDS drug trade dispute ends’, September 18
21. Carael, M (2006) ‘Twenty years of intervention and controversy' in Denis and Becker (eds) (2006) ‘The HIV/AIDS epidemic in sub-Saharan Africa in a Historical Perspective'. Online edition pp 34
22. Connor E.D. et al. (1994) 'Reduction of maternal-infant transmission of Human Immunodeficiency Virus type 1 with zidovudine treatment' ,The New England Journal of Medicine, Vol. 331:1173-1180, November 3, No. 18
23. CDC (1998) 'Short course regimen of AZT proven effective in reducing perinatal HIV transmission: offers hope for reducing mother-to child HIV transmission in developing world', Press release, February 18