Aids and AZT
PRESSURE on the government to make AZT
or nevirapine available to pregnant women with HIV/Aids is bound to
mount. The World Conference on Aids in Durban in July will turn the
spotlight on the South African stance and could well be the scene of
demonstrations by local activist groups, as well as critical attack by
experts attending the conference. Secondly, the HIV/Aids Treatment
Action Campaign (TAC) plans to launch legal action very soon.
"I believe there is a very strong legal case under the Constitution
for giving AZT to pregnant women, both as regards the rights of
children to health care and the reproductive rights of women," says
Mark Heywood of the Wits Aids Law Project, which is co-operating with
TAC. Although constitutionally the right to health care can be limited
in certain circumstances on grounds of cost, Heywood does not think
this argument would apply: "AZT can be shown to be cost effective and
affordable," he says. "The government knows it’s on weak ground when it
comes to AZT for pregnant women."
In fact the Aids Law Project was about to initiate legal action last
year and only decided to hold back following a meeting with health
minister Dr Manto Tshabalala-Msimang in which she gave them what turned
out to be "false reassurance". The government changed its ground after
President Thabo Mbeki claimed that a large body of scientific
literature showed that AZT — a medication on the World Health
Organisation’s essential drug list — was potentially toxic and that it
would be irresponsible to prescribe it for HIV patients until its
safety was established.
As Dr Ian Roberts, special adviser at the department of health, said
in a recent interview: "Good political decisions are underwritten by
good science." (see interview below). But Mbeki’s information has been
derived from individuals who, although undoubtedly sincere, are not
members of the mainstream scientific community. They include Charles
Geshekter, a lecturer in African history at California State
University, and Anthony Brink, a Pietermaritzburg lawyer, both of whom
contributed opinion page articles to a debate on Aids in the Citizen.
Brink is believed to have referred the president to a South African
website promoting the discredited theories of Professor Peter Duesberg,
the Californian molecular biologist — that HIV does not cause Aids and
that it is the drug AZT that destroys the immune system.
The puzzle remains why the president and his health minister should be
guided by them rather than expert bodies such as the Medicines Control
Council and the Medical Research Council. One answer lies in the
specifically African perspective on the disease that they offer. In his
article, "The Epidemic of African Aids Hysteria" (Citizen, September
16, 1998), Geshekter argues that Africans have long suffered the
symptoms of Aids — weight loss, chronic diarrhoea, fever and persistent
coughs — but that these symptoms are due to the environmental risks
caused by poverty not to a sexually transmitted virus. Researchers have
wrongly redefined these symptoms as HIV/Aids and then assumed that, as
in the West, the epidemic of immune deficiency was driven primarily by
sexual promiscuity. As a result, he says, health professionals have
fixated on condom distribution or evangelistic demands for behaviour
modification instead of concentrating on improving water quality,
sanitation and diet.
Geshekter also suggests a more sinister agenda: "Having millions of
Africans threatened by Aids makes it politically expedient to use the
continent for vaccine trials or for distribution of severely toxic
drugs like AZT that radically affects the liver and kidneys, causes
muscular diseases and destroys red blood cells."
For Mbeki, a committed Africanist, who is trying to keep public
spending under control in a country facing the onslaught of Aids, there
must be multiple attractions in this kind of "theory". It sets Africa
apart from the West, downplays the weak points of sexual behaviour and
exploitation of women, highlights poverty — which no one can deny is
the essential social context of the epidemic — and thus increases moral
leverage on the developed world for debt relief. And finally it
demonises Western researchers, drug companies and, of course,
AZT.
An interview with Dr Ian
Roberts
HEALTH DEPARTMENT watchers on the look-out for any hints of change in
government policy on Aids and its treatment have noted that Dr Ian
Roberts popped up at the Conference on Retroviruses and Opportunistic
Infections in San Francisco in February. Roberts is a special adviser
in the department, and his socialist perspective was a crucial
influence on former health minister Dr Nkosana Zuma. While in America,
Roberts gave an interview to Emily Bass, a specialist writer on
HIV/Aids, for the internet magazine, Salon. The interview is not just
significant because it gives insight into Roberts’ thinking, but also
because it indicates the intense interest that international
specialists are taking in South African policy — especially on the
issue of mother to child transmission of the disease. Refocus reprints
some of the key passages below. (The full text is available on
www.salon.com)
Bass: Vaccines are a huge priority
right now. Where do you see progress coming from in this
area?
Roberts: It has to be global effort. All relevant people need to come
together one way or another and lose protectionism and desire to
leverage themselves and just focus on what we need. It’s not a question
of do we have the budget. It’s that if we don’t solve it, the
ramifications are going to be enormous. In a sense, it’s a shame we
don’t have complete, total global dictatorship for a year where one
individual says, "Either you do it or you die."
Bass: Do you see this global
involvement happening?
Roberts: On the flight here, I flew next to someone from Shell — it
could have been anybody, from any company. I always ask people the same
question, partly because it gives them a level of discomfort: "What are
you doing about Aids? What is your company doing about Aids?" He said,
"Well it’s not Shell’s problem." If I had a company, or was managing
director of Shell now, I would be very focused on what I could do. Not
only because my market place is going to change tremendously, but also
because there’s a responsibility when a continent is facing what we
are. Three or four months ago, I didn’t have the same sense of urgency
I have now, so I can understand if Shell doesn’t have that urgency.
Still, it seems surprising to me that it’s not there.
Bass: So, something’s changed for you
recently. Where has your sense of urgency come from?
Roberts:It’s hard to say exactly. One thing may be that there are very
few people that I’m close to, or that I like, and one of them died
recently of non-Hodgkin’s lymphoma [an Aids-related illness]. He was a
fashion designer and worked for Missoni with my wife.
Bass: What about something like
nevirapine or AZT for stopping pregnant women from passing the virus on
to their babies? Last year a Ugandan study found that a $4, two-pill
regimen dramatically reduced the levels of transmission. Will you move
forward with that?
Roberts: Often, the easiest answer is for policy advisors to just roll
out a [new policy]. So you can say, "We’ll roll out nevirapine," and
then Aids activists can congratulate themselves and say, "We pushed the
government into this"; researchers can congratulate themselves and say,
"Wonderful initiative — we did all the work." Government can stand up
and say, "We’re really doing something in Aids now" — and at two years
old, the kiddies are still dying, and everyone’s lost hope. That’s not
saying we shouldn’t intervene. Once we know the results [of South
African trials of this regimen], we’ll go back to the minister for her
policy decision, which may be that we need more clinical trials, or it
may be that we’ll roll out a new policy.
Bass: That almost seems to be in
conflict with the urgency of what’s happeningin terms of
infections.
Roberts: What I want to avoid is self-perpetuating publication of
papers. Science can either produce more publications or it can impact
on the social reality of people infected. You have to have some solid
evidence about what you’re doing. The danger of rolling out public
health policies based on anecdotal evidence is that they’re very
difficult to reverse. I think we can be quite loose and make best
guesses, but good political decisions are underwritten by good
science.
Bass: Still, at this conference, some
researchers have been surprised by your hesitation to recommend ideas,
like the $4, two-pill nevirapine regimen, that might work, that have
been proven to work in other African countries.
Roberts: They’re entitled to their opinion. We’re waiting for the
SAINT [South African Intrapartum Nevirapine Trial] study, which will
provide important information specific to South Africa. In addition,
we’re looking at the total picture — trying to understand reducing
transmission in the South African context. I don’t dispute that
nevirapine lowers transmission, but we have to deal with the problem
from a holistic perspective. Treatment might be important, it might not
be. Perhaps it’s more important to improve the child’s quality of life
[such as clean water, food, shelter].