PRESIDENTIAL AIDS ADVISORY PANEL REPORT
SOCIO-ECONOMIC FACTORS IN
THE CONTEXT OF HIV/AIDS
Socio-economic factors that enhance the spread of AIDS were not discussed extensively in the two meetings of the Presidential Aids Advisory Panel. They formed part of discussions on other issues and were used as contributing factors or otherwise in defending the various theories. Prof Abdool-Karim made it very clear on several occasions that in South Africa, "it is not enough to educate, it is not enough to inform, it is also necessary to create the social environment to implement health promotion in its broadest context". What is needed is the training of healthcare workers in implementing solutions to the needs.
The socio-economic factors that are related to the spread of HIV/AIDS include:
7.1 Malnutrition and sanitation
The issues of malnutrition and sanitation were discussed at both meetings. These two factors exacerbate the spread of the disease and hamper recovery, not only among HIV-positive patients but also among those with sexually transmitted diseases.
Prof Duesberg claimed that the epidemic is restricted to a minority that appears to have in common malnutrition and poor sanitation. Dr Giraldo agreed that the immune system of the foetus can be destroyed if the mother is severely malnourished. He went on to say that malnutrition and nutritional and vitamin deficiencies are a risk factor for AIDS. He reiterated that transmission of HIV can be prevented by ensuring that mothers in South Africa have good levels of vitamin A. Dr Gray interjected that she had yet to see a report that a vitamin A-deficient HIV-negative mother gave AIDS to her baby.
Endemic diseases such as TB and bacterial diarrhoea plague South Africa, along with many parts of Africa. The need for public health measures that will improve the health of the population in general will also have an impact on the spread of AIDS.
The panellists were divided as to whether breast-feeding transmits HIV or not. Dr Giraldo argued that "there is no objective evidence for the hypothesis that neither HIV nor AIDS can be transmitted from mother-to-child through breast milk" as these beliefs originate from non-controlled surveys. Even those who believe in the transmission of HIV and AIDS through breast milk, such as Dr Coll-Seck, argued that although it is important to inform HIV-positive women that they can infect their children through breastfeeding, the children are likely to die of malnutrition and disease unless there is clean drinking water and a viable alternative to breastfeeding. Dr Stein suggested that one factor that is important in Soweto, for example, is that clean water is universally available, which makes it safer and more practicable to bottle-feed, and there are often funds available in the family to purchase baby feeding formula.
The solutions offered throughout are to adopt a preventative strategy as a policy that will involve commitment from services and also counselling to women and, ideally, also those close to them.
The issue of children, with or without AIDS, that are orphaned when their parents die of AIDS was not discussed in any significant detail at either meeting. Prof Whiteside quoted Dr Makgoba as saying that South Africa faced an increase in mortality among the people it could least afford to lose, the young people in society, and that the country should not lose sight of the equally important issues that many of those who died were leaving behind orphans. Dr Rasnick requested data to support the claim that AIDS deaths have generated orphans.
7.3 Ethics and human rights
Panellists who advocated that HIV/AIDS patients should be given drugs to assist them in recovery argued that it was unethical to deny drugs to HIV/AIDS patient, regardless of which laboratory they come from, as long as the drugs are known to be beneficial. The main concern of the panellists opposed to anti-retroviral therapy was the ethics of administering such drugs if they are not properly tested through a controlled study. Prof Duesberg maintained that there are no studies to show that AZT and other anti-retroviral drugs have been tested on animals and have shown that they benefit the animals, or at least have no side effects. Additionally, there is a solid body of published research that implies that these drugs are indeed harmful, and, according to some, it is therefore unethical to administer drugs whose clinical actions in relation to dosage and time of application are poorly known, or not known at all. Prof Montagnier held that such drugs are toxic and should not be administered without appropriate monitoring, while Dr Vella maintained that, due to new techniques, drugs are now less toxic than previously.
The panellists who disputed that AIDS is caused by HIV declared it unethical for any person who reacted positive to HIV test to be told that they suffer from a deadly disease and face certain death unless they received treatment.
7.3.2 Human rights
Within the South African environment, the most important issues related to a non-discriminatory supportive social environment, according to Dr Bertozzi, include issues related to social conditions, the status of women and other marginalised groups in society, inequality, the alleviation of poverty and human rights.
However, while South Africa is undergoing transformation in terms of human rights, the issue of virginity testing is still prominent in our society. This, according to Prof Mhlongo, is unacceptable and an insult to black South African women.
The AIDS epidemic highlights the dynamics of gender-based inequalities, as shown by an already cited survey in KwaZulu-Natal, which demonstrated far higher levels of HIV infection among women than among men in the age groups 20 to 24 and 25 to 29.
7.4 Sexual behaviour
The only data on sexual behaviour came from an international comparison by Durex to evaluate the commercial potential to sell condoms, which was presented by Dr Fiala. The data showed that Americans and Europeans are in the lead when it comes to the number of sexual partners and that South Africans as well as Thailanders are rather average. Americans and Europeans also have the highest frequency of sexual intercourse.
Seroprevalence studies indicate that more homosexual men and fewer of the general population are diagnosed with HIV in developed countries, while the opposite is true for the African population, especially in East and Central Africa.
Dr Giraldo argued that among male homosexuals the main cause of AIDS is drug abuse.
It was argued that the link between HIV and cofactors might explain why the epidemic in Africa is mainly heterosexual. It might relate directly to the high incidence of sexually transmitted disease and practices such as dry sex.
Age at first sexual encounter is an important risk factor in HIV infection. In many countries in sub-Saharan Africa, girls become sexually active at an earlier age than boys. They also tend to have sex with older men. Data have already been cited on the higher HIV-infection rates among girls than among boys aged between 15 and 19. A further risk factor for young women is that studies have shown that in some societies, initiation into sex often involves coercion, increasing the risk of trauma during intercourse and the potential for HIV transmission.
Most panellists maintained that addressing gender issues and reducing the risk of rape were very important factors in reducing the spread of HIV. However, Dr Duerr made the point that there are very few data on the efficacy of post-exposure prophylaxis in rape victims. Prof Abdool-Karim recommended that, in the case of rape, the panel should advise the administration of a combination of two anti-retroviral drugs, which would mean a very short course of anti-retroviral therapy. He was, however, opposed to recommending a policy of administering the drugs to everybody that was raped.
Stigmatisation of HIV sufferers is very common in South African society, as is the case in other African countries, Asia, Europe or the USA. Changing people’s attitudes is not easy.
The reduction of stigma and discrimination should be considered seriously with particular attention to young women and people living with HIV and AIDS. There is a need for legal protection for such people and for more openness on this disease. People living with HIV and AIDS, their families, and ‘at risk’ groups such as sex workers and migrants are often subject to outright social alienation.
Those panellists who dispute that HIV causes AIDS declared stigmatisation and ostracism of HIV-positive persons as particularly unfortunate.
Protection of the right to confidentiality and freedom from inhuman treatment has been proved to encourage and facilitate people seeking voluntary counselling and testing.
During the first Presidential AIDS Advisory Panel meeting, it was suggested that the initial spread of AIDS originated with promiscuous, homosexual drug users, from Los Angeles, through the United States, into Europe and various other countries. However, the concern was raised that certain other, possibly toxic factors, had not been taken into consideration with regard to the spread of the AIDS disease.
A puzzling bit of information to some of the panellists was the repeated claims that AIDS has wiped out whole villages in Africa in a matter of weeks or months, whereas nothing like that had ever happened in the USA or anywhere else, even among the most sexually promiscuous society that ever existed – i.e. people that frequented homosexual night-clubs and bath houses in San Francisco, New York and Los Angeles in the 1980s.
Since it seems that most of the people infected with HIV in South Africa are black, any sex theory about the transmission of HIV/AIDS would have to postulate that African people are highly promiscuous. Moreover, Dr Fiala had presented figures that showed that Europeans and Americans are much more highly promiscuous than people in South Africa, or in Africa as a whole (see section 2.5.2).
7.4.4 Condom use
According to the macro international DHS surveys, which are used by a whole range of agencies, condom are used between 60% and 80% of the time in the case of first sexual acts in the USA and Europe, compared to only 14% in South Africa. This shows that people are not adapting their behaviour, despite the fact that there is a high level of knowledge in many South African communities about the nature of AIDS and the fact that it is sexually transmitted. However, Dr Fiala cited contradictory data from the Deutsche Latex Forschung that suggested that condom usage in Germany increased only from 2 to 2.3 condoms per year per capita between 1980 and 1995.
Prof Abdool-Karim suggested that it is necessary to create the social environment to implement health promotion in its broadest sense when one is looking at creating condom use as the normative behaviour – to bring about a change in mindset that it is ‘cool’ to use a condom.
7.4.5 Issues of economics
Reference was made to a World Bank study that claimed that post-exposure prophylaxis is only likely to be cost-effective where the probability of HIV infection in the course of rape is high. Dr Giraldo, however, claimed that pharmaceutical companies would welcome such an idea, as they would commercialise the production of anti-retroviral drugs, syringes, condoms, formula meals and so on. He criticised the World Bank for promoting international loans to get Africa to purchase AZT and other anti-retroviral drugs and condoms as well as do more HIV testing. This, he claimed is bound to increase poverty in Africa and increase the wealth in the west.
Western Blot tests for the confirmation of HIV infection are not used in South Africa not only because they are indeterminate in their results but also because they are expensive and are not practical for developing countries.
Panellists who advocated of anti-retroviral drug therapy maintain that it is cost-effective in preventing hospitalisation, which is the most expensive aspect of caring for HIV-infected individuals. Studies by Neil Soderland have shown that, if the costs of therapy could be reduced to between 10% and 20% of their current costs, it would bring about a cost saving in the country. This would affect only the cost of the healthcare system, and not costs in terms of the impact of AIDS on the economy, or lost education opportunities, training and skills. These are aspects of the broader impact of the epidemic on the country.
Prof Montagnier suggested that adaptation of the treatment could serve to make it more accessible and affordable.
However, Dr Giraldo suggested that the only rational way to stop the spread of the AIDS epidemic in the African continent is by finding solutions to the economic disparities that are rampant.
7.5 Vaccine development
The main criteria for a vaccine for use in South Africa are that it should be suitable for South African conditions and sub-types of virus, as well as affordable for South Africa, its neighbours and the rest of Africa. Dr Prozesky reminded the meeting that with almost every virus-caused disease, real progress in fighting the disease had only been made with the development of a vaccine, often leading to effective eradication.
7.6 Summary and recommendations
As Dr Sonnabend put it: "It is not simply the cost of drugs. We need a whole lot more. We need the capacity to provide for people and to be able to monitor." Starting treatment too early increases the cost of treatment without being appropriately effective.
Dr Coll-Seck very clearly suggested an efficient system for monitoring and evaluating the following recommendations to ensure that they would be helpful, not only to South Africa but also to the countries and continents in the developing world:
- Improving the social environment.
- Reviewing laws (both customary and written) and their implementation to protect the safety of people living with HIV and AIDS and their families.
- Initiating strategies to negotiate for reductions in the price of drugs, local production and generics.
- Improving public awareness and use of safer sex practices in order to stop the transmission of HIV and sexually transmitted diseases.
- Improving sanitation and public health measures.
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