SOUTH AFRICA: Early HIV treatment may be cheaper than thought

Photo: UNAIDS

HIV prevalence, not eligibility, drives up patient numbers and cost

MANZINI, 13 September 2010 (PlusNews) – Research by South Africa’s University of the Witwatersrand and Boston University in the US, has found that starting HIV-positive people on antiretrovirals (ARVs) earlier, and at a higher CD4 count (a measure of immune system strength), may be cheaper than previously thought.

After years of debating the financial feasibility of starting those in need of ARVs at a CD4 count of 350 instead of the current threshold of 200, research has shown that it would only add 13 percent to the cost of South Africa’s national ARV programme if improved drug purchasing systems and task-shifting strategies were implemented.

Activists and government have duelled for years over whether the country could afford the new treatment guidelines, including better drugs and earlier treatment initiation, in keeping with the World Health Organization (WHO) recommendations.

South Africa issued its first revised HIV treatment guidelines in six years�in April 2010. The new guidelines�featured less toxic ARVs, but access to treatment at a CD4 count of 350 was only extended to a selected group of high-risk patients, such as pregnant women, infants and tuberculosis patients.

Starting patients on ARVs at lower CD4

The growth in numbers of patients on [ARVs] over time, as a result of prevalence and sheer need, is higher than the growth in the number of patients as a result of increases in eligibility

counts has been linked to a greater likelihood of opportunistic infections and poorer patient outcomes, but government argued that it could not afford to extend earlier treatment more broadly. WHO recommends that all HIV-positive patients start treatment at a CD4 count of 350.

The findings were part of a study that estimated the costs of implementing South Africa’s current guidelines as well as the full�WHO HIV treatment recommendations between 2010 and 2017.

Researchers combined mathematical models with costings and patient data collected from two Johannesburg ARV clinics over several years to estimate treatment need, patients lost to follow up, and treatment costs associated with each set of guidelines.

Under the current guidelines, the government will have spent about US$9.8 billion on treatment by 2017. Implementing the WHO recommendations by starting people on treatment earlier would cost about $11 billion over the same period.

Both price tags include savings of around $5.6 billion from sourcing drugs at internationally competitive prices and implementing task-shifting strategies, specifically nurse-initiated and -managed ARV treatment, with ARV dispensing by pharmacy assistants.

Prevalence, not eligibility, drives up patient numbers

Researchers also estimated that by 2017 about 3.5 million people would have started taking ARVs under the current guidelines, but earlier treatment would increase that figure by 400,000 patients.

“The growth in numbers of patients on [ARVs] over time, as a result of prevalence and sheer need, is higher than the growth in the number of patients as a result of increases in eligibility,” said researcher and Boston University assistant professor Gesine Meyer-Rath during her recorded presentation of the study at the 2010 International AIDS Conference in in Vienna, Austria.

“If the South African government keeps doing what it said it would do – that is, put everyone who needs it on treatment – that will already drive the cost of the programme much more than decisions about eligibility, which will only drive costs at the margins,” she said.

Data to drive advocacy, shape health systems

While the study found that� implementing earlier treatment would cost government about 10 percent of the national health services budget by 2012; the current guidelines would work out to just slightly less at around 8 percent.

Dr Francois Venter, head of the Southern Africa HIV Clinicians Society, discussed the research at the recent annual meeting of the Rural Doctors Association of Southern Africa (RuDASA) and noted that, given the medical expenses averted with treatment, the cost was worth it.

“It seems to me that if 47 percent of your deaths are HIV-related, then 10 percent of our budget isn’t a lot to pay,” he told IRIN/PlusNews.

“We [Reproductive Health and HIV Research Unit at Witwatersrand University] have done some evaluations and found that if you put someone on ARVs you stop at least one hospitalization and several clinics visits,” he said.

In the context of decreased international aid, cost-saving will become increasingly important, Venter added.

“We need to make resources go further – whether it’s rich South Africa or poor Malawi – those countries really need to think about working smarter,” Venter he told IRIN/PlusNews. “If you employ a little creativity, some good people, and a little research money, you could go a long way in telling us how to run our health care systems a whole lot better and smarter.”

The South African government funds about 80 percent of its national ARV programme, making it an exception in a region where the health budgets of many countries – Mozambique, Madagascar – are heavily supported by international donors. With an HIV prevalence of about 18 percent, South Africa has the world’s largest ARV programme: more than a million people on treatment.

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Photo: Stephen Starr/IRIN

DAMASCUS, 9 September 2010 (IRIN) – A top UN official warns that Syria’s drought is affecting food security and has pushed 2-3 million people into �extreme poverty�.

During a mission to Syria which ended on 7 September, Olivier de Schutter, UN special rapporteur on the right to food, said 1.3 million people had been affected by the four-year drought, 800,000 of whom had had their livelihoods devastated.

�The situation is really bad,� said Selly Muzammil, spokesperson for the World Food Programme (WFP) in Syria.

In June the Food and Agriculture Organization (FAO) in Syria said the drought had ended but that inconsistent rainfall was causing crop failures. Other UN agencies say the drought is ongoing.

Schutter said four consecutive droughts had affected Syria since 2006, with the drought in 2007-2008 being particularly devastating. “The losses from these repeated droughts have been significant for the population in the northeastern part of the country, particularly in Al-Hasakeh, Deir Ezzor and Al-Raqqa.�

Small-scale farmers have been worst affected. Many farmers have not been able to cultivate enough food or earn enough money to feed their families. Herders have also lost 80-85 percent of their livestock since 2005, according to UN figures.

Thousands have left northeastern areas and live in informal settlements or camps close to Damascus. Experts warn, off the record, that the true figure of those living in �extreme poverty� could be higher than the 2-3 million estimate.

Wheat

The drought is also threatening food security. Whilst the government says it is self-sufficient in wheat – the primary strategic crop in Syria – production has not matched demand.

This year�s yield was 3.3 million tons, compared to demand for 3.8 million tons, according to government figures. Wheat has been imported.

�Syria has enough to stocks for the shortage at the moment. The problem is that poor families have had several years of bad crops so their resilience capacity is low. Many families now don’t have access to credit, for example,� said Mario Zappacosta, an economist from FAO’s trade and markets division.

The biggest challenge Syria is facing is altered weather conditions such as inconsistent rainfall, according to officials at the Ministry of Agriculture. Adversely affecting farmers, it is not clear whether the changes are natural fluctuations in the climate or permanent changes due to global warming.

Water sources have also been permanently affected. Farmers used wells to draw on groundwater resources because of a lack of rainfall. The situation is exacerbated by the inefficient use of water. Schutter said the dropping of groundwater tables was a �serious concern�.

The Syrian government and the UN have been handing out food to those affected and working to implement more efficient agricultural policies. Central planning is gradually being replaced by indicative planning with an agricultural support fund providing subsidies for certain strategic crops.

Earlier this month an irrigation project was launched in the lower Euphrates basin, near Deir Ezzor to reduce water drawn from groundwater reserves.

But Schutter warned that the Syrian drought appeal was not receiving enough money as aid had been politicized. Only 34 percent of the total funds requested had been received, according to the UN. One of the effects of this has been to limit WFP food parcels to 200,000 of the 300,000 people it had hoped to target during distribution in June.

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Photo: FAO

Malagasy Migratory Locust swarm in the Menabe Region in May 2010

JOHANNESBURG, 9 September 2010 (IRIN) – The UN Food and Agriculture Organization (FAO) has warned of an “imminent and severe threat from the increasing number of swarms of Migratory Locusts” in Madagascar, requiring “immediate response assistance to prevent a humanitarian disaster”.

The warning came at an Emergency Assistance to Locust Control meeting on 8 September in the capital, Antananarivo and a few days after�USAID’s Emergency Transboundary Outbreak Pest (ETOP) Situation Report for August with a Forecast till mid-October,� published�similar concerns.

“There is a likelihood of extensive breeding … Should that occur, Madagascar will experience one of the most severe locust outbreaks in recent years, and will need to launch large-scale control interventions through mid-2011,” ETOP said.

Dealing with the locust threat will cost about US$14.5 million; so far $4.7 million has been received from the UN Central Emergency Response Fund (CERF) and $490,000 from the FAO Technical Cooperation Emergency programme.

Annie Monard, the Rome-based FAO locust officer who will be arriving in Madagascar in the next few days, told IRIN that the indicators were of “serious concern”, as the locust population was “so high” that they had been able to “escape the traditional area” [in southwestern Madagascar] and swarms had been observed along the east coast and in the whole mid-west.

A four-year locust plague ended in 2000, when only the far north of the world’s fourth biggest island was spared from invasion by the Malagasy Migratory Locust (Locusta migratoria capito), and even the east coast, usually considered too humid, was affected.

This insect can produce a new generation almost every two months, and consumes roughly its own weight in vegetation – about two grams – every day. Monard said that while travelling in a helicopter in 1998 she looked down on a swarm covering an area about 30 km by 70 km. “It was like a huge cloud moving over the whole plain.”

Undetected

The build-up of locusts occurred undetected during the previous rainy seasons (from October to April) while the capacity of the government’s Locust Control Centre (CNA) was weakened as a result of the socio-political situation in the country, said an FAO document, Emergency assistance to locust control in Madagascar.

Madagascar has been enmeshed in a political crisis since 17 March 2009, with foreign aid cut to emergency humanitarian assistance, and only if justifiable, since the “illegal” transfer of power in which President Marc Ravalomanana stepped down in favour of opposition leader Andry Rajoelina.

The recently reported swarms outside their outbreak area indicate a major upsurge is on the rise. Past experience demonstrates that a plague could evolve

The current prevailing dry, cool weather is unsuitable for breeding, but with the onset of the rains and higher temperatures, rapid reproduction occurs. As population density increases, the insects undergo behavioural and physical changes from solitary to gregarious, forming swarms that devastate crops – every million locusts eats one ton of food.

“The recently reported swarms outside their outbreak area indicate a major upsurge is on the rise. Past experience demonstrates that a plague could evolve if the locust population remains unchecked at this stage. The ensuing plague would persist for many years, with devastating consequences for food security,” said the FAO emergency assistance document.

“Currently immature locust swarms will mature and start breeding at the onset of the next rainy season, and concentrations of wingless young locusts (hopper bands) will develop from October to December 2010. These bands will attack primarily the eastern parts of the outbreak area, which will receive the first rains. However, they will also affect the mid-west, which has been already invaded by swarms.”

Monard said surveys and preparations had been undertaken since July this year to begin a spraying campaign ahead of the onset of the rains, using “three families of pesticides” to keep the insects in check.

Three families of pesticides

Conventional pesticides will protect threatened crops, Insect Growth Regulators will control hoppers [wingless locusts], and biological pesticides will be applied in ecologically sensitive areas, such as “natural reserves, national parks and populated areas”, the FAO document said.

Spraying an estimated 500,000 hectares would take place when the locust populations were most vulnerable, and they “are not yet winged and less mobile, are marching, and at their most sensitive to pesticides,” Monard commented.

However, equipment had to be pre-positioned ahead of the rains, as the roads to many areas threatened by locusts would become impassable during the rainy season, the FAO said.

FAO noted in its August Locust Response report that “The livelihoods of the rural communities, already precarious especially in the Great South [of Madagascar], are under immediate locust threat.” Around 70 percent of Madagascar’s roughly 20 million people live below the poverty line, and 50 percent of children under the age of five are malnourished.

Up to 52 communes in the region are predicted to be food insecure by the end of 2010, and 10 of these – containing around 100,000 people – are seen as acutely food insecure, according to an evaluation by the World Food Programme in July 2010. All the food insecure communes are threatened by locust swarms.

The CNA said more than 460,000 rural households, or 2.3 million people, would be affected by locust invasions, and potential crop losses could amount to at least $135 million.

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