KENYA: Musa,* “When the results came back we didn’t think they could be true”

Photo: Richard Etienne/IRIN

JOHANNESBURG, 10 September 2010 (PlusNews) – For the past five years Musa* and his wife have known that their HIV status was different [discordant]. Now the father of two healthy, HIV-negative children, he spoke to IRIN/PlusNews about how he and his wife – like many couples – did not know discordancy existed, and had trouble finding the answers and services they needed.

“We were actually married in 2003, but in 2005 we were supposed to have a baby. At that moment in my career, I was [very successful] … I thought my life was made until she went for antenatal [services].

“At that time, in Kenya [health workers at antenatal clinics] used … to tell the women, ‘Make sure you come with your [HIV test] results, and that of your partner, at your next visit.’

“To cut a long story short, she [his wife] kept on pestering me, saying, ‘We need to go for the [HIV] test because we need [to take] the results … to the antenatal clinic.’

“Before we went and tested, I decided to go and do my own [test], just to be on the safe side. After I did my test, I was then confident enough – [because] … I am the one who has tested – to say [to her], ‘When did you want to go [for the test]?’

“When the [HIV test] results came out, I mean, we thought it couldn’t be true. We thought, ‘There is no way that this could be happening.’ So we did two, maybe three other tests, and they were discordant.

“We were put in a support group – a ‘post-test club’. When we were in [that group] I think I asked that doctor so many questions that he got angry because he could not explain [why our HIV test results did not match].

“We’d been together for, like three years, and one is negative and one is positive – how could that happen? [I asked him,] ‘Can you kindly please explain that in simple terms?’

“We were in a dilemma because, first of all, who do you talk to about this? This is Africa. If you talk to your family, they’ll tell you – in fact they will take the initiative – to kick the [infected] partner out of the house, yeah?

“No one had answers, no one could help us. Programmes were more focused on the infected ones. What they did not know, or care to know at that time, was what was happening to the negative partners. What was the state of their mental health?

“We were then forced to form ourselves into something that was beyond that post-test club. I do not want another couple to find themselves in the place that we found ourselves, where someone cannot answer their questions.”

llg/ks/he

source.irinnews

Photo: Rebecca Murray/IRIN

Many Cambodians struggle to keep their land

KOH KONG, 13 September 2010 (IRIN) – Forced evictions and land grabbing are nothing new in Cambodia, according to the UN Office of the High Commissioner for Human Rights (OHCHR), but it is new for communities to fight back.

“If we don’t have our land, we cannot live,” Yi Kunthear said. In August, she was reportedly beaten unconscious by sugar plantation workers while trying to defend her land. “We will block our land if the company tries to take it again.”

Kunthear, 25, grew up on her family’s small farm growing rice, cassava and cashew nuts in the rural district of Sre Ambel, Koh Kong Province. But in 2009, the Supreme Court ruled that her family’s land, along with that of her 34 neighbours, belonged to Heng Huy, a local businessman.

On 27 August, Sre Ambel villagers blocked the road as Huy’s bulldozers rolled in, joined by Kompong Speu provincial farmers also made landless by Senator Ly Yong Phat’s giant sugar company purchase.

According to Cambodia’s revised 2001 land law, if farmers prove they have worked their land for five years, they are entitled to own it; nevertheless, about 90 percent of the country’s 14.5 million inhabitants do not hold title deeds to the land they live and work on, the OHCHR reports.

Village documents show Sre Ambel’s farmers have worked the land since the 1980s. However, Huy says he bought the title for the 779ha land concession in 1993.

And while national organizations such as the Community Legal Education Center (CLEC) have defended the landless in court, Sre Ambel’s farmers have stepped up their resistance by registering a lawsuit in Koh Kong’s provincial court against the Heng Huy Company, along with its UK buyer, Tate & Lyle.

Challenging the EU

Community representatives from sugar-growing provinces – an industry dominated by ruling party member Phat – have challenged the European Union’s “Everything But Arms” tax-free policy for Cambodian sugar exports.

They are supported by national human rights watchdog, Licahdo, the grassroots activist Community Peacebuilding Network and land-rights INGO, Bridges Across Borders Cambodia (BABC).

Photo: Rebecca Murray/IRIN

Yi Kunthear was beaten while defending her plot of land

“The EU is effectively subsidizing land grabbing in Cambodia by giving preferential treatment to companies that have produced goods on stolen land,” David Pred, BABC executive director, told IRIN. “Large-scale land concessions for sugar production have displaced and impoverished thousands of Cambodian families in three provinces.”

Earlier this month, the EU Charge d’Affaires in Cambodia, Rafael Dochao-Moreno, said the EU was gathering information to better understand the policy’s impact, although it was not investigating possible human rights violations.

Forced evictions

Recent executive sub-decrees in Cambodia have seen fertile, forested public land reclassified as private state property, explained Chum Narin, CLEC’s land and natural resource programme head, who is involved with the Sre Ambel case.

Thousands of families around Phnom Pehn’s Boeng Kak Lake will be uprooted to make way for developers, according to the Cambodian Human Rights Action Committee (CHRAC), a coalition of over 20 organizations working on this issue.

Some 133,000 people – 10 percent of Phnom Penh’s inhabitants – are believed to have been affected by such evictions since 1990, according to a 2009 Licahdo report.

And more than 250,000 people in the 13 provinces where CHRAC works have been hit hard by land grabbing and forced evictions since 2003, it says.

Numerous protesters and petitions have targeted the Prime Minister Hun Sen but to little effect. However, grassroots community networks – from the Koh Kong farmers to the indigenous in Ratanakiri – are beginning to grow.

Dam Chanthy is a local activist from the remote, mineral-rich province of Ratanakiri. She became outraged at the exploitation of the region’s indigenous people, especially after she witnessed one company trade a litre of wine for a hectare of land.

Now Chanthy, who has escaped attempts on her life,�travels around the province to raise awareness about land law, land prices, and promote health and indigenous culture, mainly through the Highlander Association.

“We believe the best way to effect human rights change here is to support and nurture the development of grassroots Cambodian civil society,” says Pred.

“The people’s organizations and networks that have emerged in recent years are demanding justice and accountability in increasing numbers. They are going to be a force to be reckoned with.”

rm/ds/mw

source.irinnews

AFRICA: Drug-resistant HIV threat looming

Photo: John Nyaga/IRIN

Drug-resistant testing is unavailable or too expensive

JOHANNESBURG, 9 September 2010 (PlusNews) – HIV-positive patients about to start antiretroviral treatment are warned not to skip even the occasional dose of their medication because of the virus’ ability to mutate rapidly and become drug resistant; but what about patients who have never taken treatment and already have a drug-resistant strain of the virus?

In Africa the extent of “primary”, or transmitted HIV drug resistance in treatment-na�ve (never treated) patients is largely unknown, but a recent study at three clinics in Lusaka, Zambia, found that nearly 6 percent of patients about to start HIV treatment for the first time already had resistance to standard first-line antiretroviral (ARV) drugs.

The study was part of a programme to monitor transmitted HIV drug resistance, as well as “secondary” drug resistance (acquired during treatment), coordinated by the PharmAccess African Studies to Evaluate Resistance (PASER) – a project of the PharmAccess Foundation, a Dutch health NGO – and part of a broader initiative to track HIV drug resistance in Africa and Asia.

PASER and its sister project in Asia – TREAT Asia Studies to Evaluate Resistance (TASER) – share their research findings with the World Health Organization’s HIV drug resistance network (HIVResNet) which monitors global trends in HIV drug resistance and advises countries on how to minimize the emergence and transmission of drug-resistant strains of the virus.

PASER has established a network of clinics, laboratories and research centres in six African countries to discover the extent and speed at which HIV drug resistance is spreading. The Zambian study, published in the Journal of AIDS on 1 September, will soon be followed by results from the five other countries.

The lead author, Dr Raph Hamers of the PharmAccess Foundation in Amsterdam, the Netherlands, said preliminary results from the other countries suggested that between 3 and 8 percent of patients who were yet to start treatment had “baseline” resistance to first-line ARVs.

In Europe and the United States, where ARV treatment became available years earlier than in Africa, up to 20 percent of new HIV patients have drug resistance. “We are all worried that we will reach similar levels in Africa,” said Hamers, adding that treatment programmes on the continent were much less regulated than Western ones, and more prone to drug supply interruptions.

Shortages of staff and resources meant treatment programmes in Africa are also often ill-equipped to pick up on patients who are failing treatment and developing drug resistance – such patients can transmit drug-resistant strains to their sexual partners and children.

I understand we have a million people on treatment, but if we don’t think about the next 20 years, it’ll be like the problem we have now with drug-resistant TB

“Imagine if one out of four [HIV-positive] people in Africa were infected with [drug] resistant viruses, and needed to immediately start second- and third-line treatment,” said Prof Tobias Rinke de Wit, programme director of PASER.

With budgets for HIV/AIDS treatment already shrinking as a result of the global economic crisis, and second-line ARVs costing at least five times more than first-line drugs, such a scenario could stall efforts to expand treatment access. Even worse, it could lead to the development of strains of HIV resistant to multiple classes of ARVs, making them virtually untreatable.

Dr Theresa Rossouw, an HIV clinician, estimates that between 5 and 10 percent of the new patients she sees at clinics in the Pretoria area of South Africa have drug resistance. “I understand we have a million people on treatment,” she said, referring to South Africa’s national ARV treatment programme. “But if we don’t think about the next 20 years, it’ll be like the problem we have now with drug-resistant TB.”

Lack of drug-resistance testing

Part of the difficulty of monitoring the spread of primary HIV drug resistance is detecting it in individuals who are not yet enrolled in a programme or subject to routine monitoring. WHO advises countries to develop surveillance systems that regularly measure HIV drug resistance in a sample of untreated patients.

Even for patients who are enrolled in care, drug resistance testing in Africa is either unavailable or prohibitively expensive. If a patient is failing treatment, doctors mainly rely on viral load (a measure of the amount of HI virus in the blood) and CD4 count testing (a measure of immune system strength) to determine whether they need to be switched to second-line drugs. In some African countries the availability of viral load is very limited, and patients are kept on first-line treatment long after it becomes ineffective.

PASER is trying to address this problem with its Affordable Resistance Test for Africa (ART-A) – a cheaper, easier-to-use test that analyses dried blood spots for HIV drug resistance – being piloted in Uganda and South Africa. “By the end of this year we’ll know how the test is performing in the field, then … you have to take it from the lab into a product, and that … could take one to two years,” said Rinke de Wit.

The new test would still be too expensive to use for every HIV patient. “Resistance testing should only be done when people are already failing [treatment],” he said. “As budgets are going down for ARVs, it wouldn’t be responsible to do [it] more widely.”

Nevertheless, a point-of-care drug resistance test would make “a huge difference”, Rossouw said. “We can prevent about a third of patients going onto second-line therapy by having this test that could pick up on resistance from an early stage.”

Doing drug-resistance testing every six months might be more cost-effective than some of the other routine monitoring, such as CD4 count testing, she told IRIN/PlusNews.

Risks of monotherapy

Rossouw said the need for programmes like PASER’s was particularly vital in light of the common use of single-dose nevirapine to prevent mother-to-child HIV transmission (PMTCT) in Africa. Mono- and even dual ARV therapy often led to the development of drug resistance, although some research has suggested that such resistance wanes over time.

In the Zambian study, most patients with primary drug resistance had resistance to a class of ARVs called non-nucleoside reverse transcriptase inhibitors (NNRTIs), which includes nevirapine as well as efavirenz – both widely used in Africa in first-line ARV regimens.

The difference in the number of men and women with drug resistance in the study was not significant. “Either single-dose nevirapine is not significant, or you could argue that females transmit their drug-resistant virus to males,” Hamers said, adding that more studies were needed before local policy-makers considered changing the drugs in their national treatment and PMTCT programmes.

Rossouw argued that African treatment programmes should start using ARVs more responsibly to avoid major problems in the not-too-distant future. “We’ve been in a type of honeymoon period with ARVs, but as we have patients that are more treatment-experienced – like they’ve seen in the Zambian cohort – the individual patient won’t respond as well to treatment,” she pointed out.

“I definitely think we’re going to end up with primary resistance, like we’ve seen in the [United] States, of about 15 to 20 percent.”

ks/he

source.irinnews