Jerry Coovadia on HIV/AIDS in Africa

Professor Hoosen Mahomed (Jerry) Coovadia
Professor Jerry Coovadia

Dr. Jerry Coovadia is a professor of HIV/AIDS Research at the Nelson Mandela School of Medicine at the University of Natal in Durban, South Africa. He chaired the 13th International AIDS Conference last July, the first time the conference was held in the continent hit hardest by the pandemic. Of the 36 million people around the world living with HIV, 23 million are in Africa. Already over 12 million children in the continent have lost one or both parents to the disease, and 11 million children in Africa carry the virus.

Original broadcast: July 23, 2001

Transcript

For the first time, we have seen some recognition of the particular issue now of HIV/AIDS which threatens not only the developing world, but if it reaches India and China, heaven knows, you won’t have too much of a world to save and no European or American society can exist untouched if there’s disorder and chaos on that level.

A year ago, the 13th International AIDS Conference was held in the South African port city of Durban. It was the first time that a major AIDS conference was held in Africa, the continent which has suffered the most from the epidemic. Of the 36 million people infected with the HIV virus which causes AIDS, 23 million live in Africa. Since last year’s conference, a great deal has been happening on the AIDS front: the UN Secretary General Kofi Annan has launched an appeal to raise between 7 and 10 billion dollars a year to combat the disease. The United Nations General Assembly decided last month to declare AIDS a global crisis requiring global action. And in a major court case in South Africa in April, pharmaceutical companies agreed that people with HIV in the developing world should be allowed to have access to cheaper anti-retroviral drugs. Eric Beauchemin spoke about these developments with the chairman of last year’s AIDS Conference was Jerry Coovadia, a professor of HIV/AIDS Research at the Nelson Mandela School of Medicine at the University of Natal in Durban. But Professor Coovadia began by discussing some exciting research he and his team have been conducting on the transmission of the virus from mother to infant.

The position in the world at the moment is that we have very powerful anti-retroviral drugs and these act at certain stages of this transmission from the mother to the baby. And those transmission routes are when the baby is in the mother’s womb, and when the baby’s being born during delivery. And the drugs we have act at those two points. And they are very, very successful indeed. So successful that in the developed world, infected HIV babies are becoming really uncommon. However in developing countries there’s another major route of transmission which is not easily resolved and that’s the area of our particular interest, and that is transmission of the virus through the breast milk. Now in the Westernised world, in Europe and the US, what’s happened is that women were told if you are HIV infected and you’re pregnant, simply take these anti-retrovirals and do not breast-feed. However in Africa and Asia, not breast-feeding is simply not an option. There are many reasons why women even though they are HIV infected and despite the fact that they would have been counseled and told “look, these are the disadvantages of breast-feeding and these are the advantages, because both exist, and these are the advantages of formula feeding and the disadvantages and you have to choose.” But women in developing countries don’t have free choice. They are constrained by their cultural environment, which is rooted in a long tradition of breast-feeding. It’s not something you can give up easily. They also live in communities where stigma and discrimination against HIV/AIDS is rampant. It’s positively dangerous to do something unusual like formula feeding which might indicate that you are HIV infected or something else. And thirdly and very importantly, formula costs money. And many poor women in Africa and Asia won’t be able to afford it. So in a word, women in developing countries have got no adequate solution to the transmission of the virus from the breast milk and that’s our main area of interest. For the present, we don’t have a complete answer, but we have some indications that the type of breast-feeding that the women give, whether they mix it with other foods or water, may be far more dangerous than if they breast fed exclusively. Now that sounds paradoxical but we have some hypotheses why breast milk alone without any additions of possibly contaminated water, contaminated foods or infected drinks might be safer than these mixed forms of feeding, that is breast-feeding plus these foods. What we think happens is probably these contaminants damage the gut and allow the virus which is in the breast milk to go through. So the answer to us is maybe to try, just breast-feeding for six months alone and nothing else. And that’s a hypothesis we’re testing out in the field here in Durban in a project which is being conducted in an Africa Centre which is a rural site about 2 hours from Durban in a place called Matubatuba. We also have projects to try and use anti-retrovirals in the babies whilst the babies breast-feeding to see if the anti-retroviral in the baby will be able to kill the virus in the breast milk. And these studies are underway but they may take a few more years to develop. Lastly, of course, we are not unaware that we must also look after children who are infected. It is inhumane to leave them to suffer without providing some hope and some succa. And to that extent we’re going to be trying out more affordable and effective forms of anti-retroviral treatment for children who are already infected.

EB: What type of other treatments? Well, the way the anti-retrovirals are given currently in the West, which is the sort of golden standard, which is what you would expect is the best level of care is just not affordable and is not practical in developing countries. So we have to find alternatives. One of the alternatives is to give these drugs for short periods of time, like little pulses, little bursts of treatment for a few works or so and then stop, and then maybe allow the immune system to build up slowly and if the virus starts taking over the immune system again, you enter again with another cycle of drugs. So this is called treatment interruptions and we think that that’s a feasible option and something we should explore and that’s what we have funding to explore for children who are already HIV infected. EB: Don’t you need a fairly modern public health system to be able to detect whether the virus is becoming stronger in the person’s body, the child’s body? Absolutely, you are quite right. It’s a subject for referral centres, so it would be something we would do in the hospital here in a referral centre. As you indicate rightly, it’s an issue which requires careful monitoring, careful evaluation and so on. The other two subjects I mentioned about breast-feeding, those are public health. No, this is specifically I would guess in the world of AIDS a high tech endeavour. EB: So it wouldn’t actually apply to a lot of people here in South Africa, for instance. Very much so. I think it’ll apply to those infants and hopefully adults who have reached the stage of the disease which requires admission into a tertiary health facility. It’s not going to be for the majority, which raises the issue of looking at establishing priorities for treatment. If we do have access to these anti-retrovirals and given the recent turn of events in the world, that seems a possibility, if we do get these drugs we’ll have to make choices about who should get the drugs and why they should get the drugs and so on. These are very difficult choices. EB: But how will these choices be made? Will it be a public discussion? Will the government be consulting with other people? Will it be doctors who will play an important role in advising the government? How will these decisions be made? In fact you’ve hit on a very crucial point. Those decisions depend on the nature of the democracy in a country. You live in an authoritarian environment, the big chief makes the decision and everyone else follows. And if you live in a democratic environment, you will have wide consultation so that people learn to accept that not everyone will have access to these treatments. It’s a fact we’ve lived with for all our lives if you think about it. Not everyone who is sick with a heart problem gets a heart transplant, not even in Holland or the States. Not everyone whose kidney packs up gets a kidney transplant. There are criteria by which you live. And each country makes its own decision. So to answer you, I don’t know how it will be handled. It’s not something that our country’s experienced in given our new democracy. I would hope that these decisions are made with the widest possible consultation of people who are going to be the beneficiaries of this and others too, and that government takes into account all points of view in coming to some decision with which government is comfortable and which is acceptable to the people. Anything short of that is going to cause more agony than having done nothing at all.

EB: Professor, can you explain what the current situation is in terms of anti-retroviral drugs here in South Africa? There was this court case. There was a settlement between South Africa and the major pharmaceutical companies. We gathered from the media that anti-retroviral drugs were going to be available to the general public quite soon in South Africa. And I’ve been hearing very contradictory things, even in terms of mother to child transmission, that that is still not happening here in South Africa. There’s no question that anti-retrovirals are not in imminent availability for the general population. That’s not going to happen. It’s going to take a long time, even if we get all the funds that people have been asking for, specifically Kofi Annan. So there’s no question that anti-retrovirals are not going to become widely available, certainly not in this country in the next few years. It’s going to take a long time, a long battle, and a detailed assessment of the advantages and the disadvantages of introducing anti-retrovirals. That’s the first point. The second point is that the court case, that victory…which it was a victory no doubt, I guess it wasn’t properly understood. What it did allow was certain pathways, certain avenues for government to get cheaper drugs from outside South Africa’s borders and I guess it allowed patented drugs which were available at cheaper prices in other countries. So Drug X which costs so much in South Africa might be…the same drug might be cheaper in our case in India or somewhere else. We have the right now to bring that drug in. But not too much more than that. We haven’t fundamentally challenged…we have challenged but we have won out on the intellectual property rights and all the issues which go with the restrictions of the World Trade Organisation. And in fact, by I think in the next five years, all of the least developed countries, including India and Brazil and all that, all the signatories to the WTO, will have to abide by the decisions of the WTO. And that is back to Square One with intellectual property rights, patents, and the TRIPPS agreement and so on, the details of which don’t need to bother us for the moment. But we are going to be in the same, a similar sort of position. However, I think given the advances that we have made now in terms of the reduction of the prices of drugs, the entry of generic companies providing competition to the research-based pharmaceuticals, I think the picture has changed and it is not easy for it to revert to its previous position where the patents were very strictly applied and the prices were exceedingly, inordinately and unjustifiably high in some countries like South Africa.

EB: But this would mean that new drugs that are developed five years from now would fall under this new regime and as a result, these drugs again would be prohibitively expensive in a country like South Africa. Absolutely, that’s the paradox I was pointing out. The victory that we had here was not complete, not by a long chalk. We will have to still struggle within these five years and at that time to try and get some equity and justice in access to drugs. The point I was making is because the landscape of drug access has changed so much and the demand from communities has been so great and successful and the concessions by the pharmaceutical sector have been gratifying, I think it’ll be very hard to go back to the old system of really high priced drugs, strict enforcement of patent rights and so on. It’s a guess, but I think it’ll be very hard for the situation that existed before to return. EB: Why is it in South Africa that drugs are still not being given to prevent mother to child transmission? I think everyone in the world knows our difficult history for the past couple of years on the issue of anti-retrovirals for mother to child transmission. But I’m really pleased that we now have programmes by government in introducing nevarapine country-wide in a phased manner which I agree with to reduce mother to child transmission. And this programme is taking place, has been taking place and has built up specific sites throughout the country to implement the programme. I think once they get over defining what the obstacles are, it will become available on a wider scale. The drug is basically very cheap and is in fact available free. So the question is really the costs of the infrastructure. EB: Is President Thabo Mbeki’s stance on AIDS, is that making the whole discussion about AIDS and your own work here more difficult in South Africa? It’s become much more comfortable in the past year. And I think that is because those sorts of views have not been expressed too loudly recently. The fact is whatever such views might be, the government has put into place programmes which are based on the fact that the drug nevarapine acts against a virus called HIV and that is the virus which causes this problem. So those views haven’t currently impeded I think these projects. What the hidden impact might be, I don’t know. Nobody knows that.

EB: Professor Coovadia, you said that it will probably be many years before anti-retroviral drugs are available to the general population and even then, they may only be available only to certain sectors, certain segments of the society. If or when this actually happens, is it possible in Africa, in Asia, in other developing countries in the world for people to take these drugs the way they are supposed to be taken because anyone who does have HIV or AIDS knows that you have to follow a very, very strict regime. You have to take drugs at certain hours, every 4 hours or every 6 hours, and if you don’t do it at that time, that window of opportunity for the drug to work closes. Is it possible here in Africa? I think it’s possible, but I think it’s going to take an effort which is almost unprecedented. However we must realise, as we have pointed out a million times now, that this is an epidemic without parallel. I mean, here is an epidemic, a plague which is without any comparison through human history. It’s worse than the Black Death in Europe and so on. That case has been so often with, to my mind, one purpose is to alert people that this cannot be treated as any other disease. This is not malaria. It’s not TB. It is HIV. And there is simply no equal to the horror and devastation it can cause. Which means that we must make extraordinary efforts as a world, as our country, as individuals to respond to that and I think that it might be that recognition which certainly has propelled the United Nations system to do things that it had never done before, to declare HIV/AIDS a security risk, to have a special session of the General Assembly, to have Kofi Annan, the Secretary General, commit himself personally to it, to ask for a yearly grant, not a loan, a grant of something like 10 billion dollars, it’s never happened before. But it gives you an idea of the appropriateness of the response to this epidemic. If you look at the developed world, there’s a glimmer of hope when Bush says at least he’s starting off with 200 million dollars, and so on. I think obviously it’s not enough but it’s the beginning of some degree of response which we need. Communities, I think communities not only in Africa, but as you have seen, whether it’s in Seattle or in Japan or in Washington are beginning to respond to the needs of the poor. It’s the scale of response which we haven’t seen since I guess in the US at least at the time of the Vietnam War. People are rising up and are saying they are not happy with an attitude which ignores large parts of the world’s suffering. communities are coming together, pharmaceutical companies are coming together, governments are beginning to respond, and the UN agencies are taking a lead in providing the sort of options that are available to these countries. I guess…and that together with the call of the Secretary General for a global fund are the beginnings of a hope which we didn’t have before. This might be fool-hardy and it might be unrealistic, but you know when you live with an epidemic like this which involves just under 5 million out of 40 million, you’re going to grasp at any straw and I guess this is one straw that many of us have been trying to clutch at.

EB: When you say 5 million and 40 million, you’re talking about 5 million infected in South Africa and 40 million people, right. Can you say that the tide is beginning to turn when it comes to the war against AIDS or it’s still too early to be saying something like that? No, there are good examples of which I was very sceptical in the beginning, but I’m beginning to understand that there are examples of real success. We trot them out at every stage but being a cliché doesn’t mean that they are not true. And there are examples in developing countries like Thailand, Uganda, and parts of Tanzania, and Senegal, and parts of Zambia and even in South Africa. For the first time, we have some figures which give us cause for hope that we may begin to turn the tide. We know what to do. It’s just that it’s been very difficult to get communities to accept what has to be done. And it’s been very difficult to get levels of resource, government and other resources from the corporate sector and from the communities and from societies based on faith and a whole lot of other components of a society to respond adequately. But I think that they’re beginning to respond. When I look at my own country, I see in the corporate sector a new recognition, a new response, that says that they must look after their workers because it’s in the interests of the industry, of the workers themselves that they maintain their HIV negative state for as long as possible and to treat HIV positive workers in a way that enhances their lives and increases that or allows them to continue at levels of productivity which maintains the existence of industry and so on. So it’s my hope that that same momentum which is being maintained by governments and UN agencies and communities will allow a new dedication to maintaining treatment. However that would be insufficient, I think, and I like many others am really concerned about the dangers of introducing anti-retrovirals, increasing resistance to the drugs, wasting money, exposing people to unnecessary side-effects and so on and so forth. There are a large number of risks. But I think given the scale of the epidemic, we must have a proportional response, and that’s what I’m hoping will be done. There are some examples and there are projects, they are not nation-wide programmes, but they are projects done in developing countries, in the Caribbean, in Africa, in South Africa, using these anti-retrovirals, and given all the requirements for discipline and dedication to your personal health which the regimes require, it’s been shown to be possible. That experience manifestly hasn’t been for many years, I mean these drugs have only become recently available, but certainly there is some experience there to give us hope that we may be able to do this on a larger scale. I must agree with you that nothing could be worse than plunging into this without the proper preparation. And the preparation for introducing anti-retrovirals will have to be of an order the likes of which we have not seen before. So it will have to be extensive public consultation and education and information and so on. It must be, the preparation of the health services, the health care services, the clinics, the hospitals, it’ll have to be the training of the doctors, it’ll have to be looking at legislation, and VAT and excise duties and heaven knows how many hundreds of things including finding the right regimens and discussing the ways of monitoring it at a cost that a country can afford. There’s a thousand things to be done before this is successful. So my view is that it must be really very, very gradually, sensitively and systematically undertaken and that’s going to take years.

EB: It’s also going to take a great deal of money because one of the things you mentioned is the public health system. If you go around in Africa, in many, many, many places, even in capitals, the hospitals, the clinics are in a horrible state. And in some places, there’s simply aspirin, if there is aspirin. Sometimes they have absolutely nothing. So to bring the public health system up to par, it’s going to be an enormous investment. I agree with you entirely. I guess it’s that sort of recognition that has made people wary of introducing anti-retovirals and people have been trying to estimate what’s it going to cost, not just the drugs, the drugs is just one part of it. And as I have indicated earlier, the companies have now agreed to reduce the costs. So they are not affordable yet but they’re certainly very much cheaper and we can start thinking about offering them to some of our citizens. But there’s a whole infrastructure cost. I mean you need ante-natal clinics, as you’ve said, labs and so on and so forth. And the estimates are, you’re talking about for Africa, for HIV, you’re talking about 3 billion dollars a year. Something like that. Now, let’s ask ourselves, is that a lot of money for the world? And it’s obviously not. I mean, you ask any economist, he or she will tell you, that the global economy is measured in trillions and trillions of dollars, the US economy alone is measured in trillions. Heavens knows the tax benefits that Bush offered his own citizens going to billions. Now in that context 3 billion dollars to me for the world to not only address the issue of AIDS, but to use the example of HIV/AIDS to do things which should have been done in any case to improve health services and stop fighting wars and stop wasting money and all that is inherently good. That you didn’t need an AIDS epidemic to justify the expenses on upgrading your health services. Now that the AIDS epidemic is not the pretext but the reason to improve the health services, I can see the expenditure of large sums of money for this purpose as a useful exercise and will do a thing which should have been done for other reasons long ago.

EB: Another thing that should have been done long ago is that the international community should have responded far more quickly than it did to the AIDS epidemic. It was clear 10 years ago what was already beginning to take place, particularly here in Africa. Are you surprised that it’s taken so long for the international community to wake up and actually act? Not really. You must remember I grew up under apartheid and we were accustomed to the hypocrisy of the world when it attempted to listen to our calls for boycott in the country, and in the meantime trading through the back door. There were many friends who supported us in that struggle, so I’m also aware that the world can’t be tarred with one tar brush. There are good governments and not so good governments. That’s been our history in the past so it doesn’t surprise me. I’m fully aware of the reasons for the debt in Africa, and I’m fully aware the skewed nature of the trade relations between developed and developing countries. I have no illusions that there’s going to be this massive change of heart in the developed world. However for the first time we have seen some recognition of the particular issue now of HIV/AIDS which threatens not only the developing world, but if it reaches India and China, heaven knows, you won’t have too much of a world to save and no European or American society can exist untouched if there’s disorder and chaos on that level. I guess people are beginning to recognise in the industrialised world that their safety, security and peace depends as much on us as it depends on them. I hope that lesson will be learned. There are people, there are cynics of course who say the West can comfortably live with millions dying in Rwanda and elsewhere and turn a deaf ear. I think they may be wrong in this one instance, and that’s what we’re banking on. But I still think it’s not going to be easy. As the economists from the States point out, to help us in AIDS will just cost the average American the price of a cinema ticket and a bag of popcorn every year. That’s all. And are they willing to make those sacrifices? I guess we’ll have to live and see what happens.

Professor Jerry Coovadia of the Nelson Mandela School of Medicine at the University of Natal in Durban, in conversation with Eric Beauchemin. Till next week, I’m GdS, stay well.