Unfairness of social and economic structures affect AIDS in Africa

EDITOR—The fact that health is fragile and determined less by health services than by the relative fairness of social and economic structures was missing from the debate on global AIDS.1 Sub-Saharan Africa contains 10% of the world's population and bears 70% of the global burden of HIV/AIDS. It also exists on 1% of the global economy and, with the recent economic slump, this figure is falling. In January Zambia heard that the mining group AngloAmerican is pulling out of copper production (which accounts for 75% of the country's export earnings). The mines are likely to close in the next 10 months, putting 9500 miners and 1600 other workers out of work. These men will migrate in search of new work—one of the many social factors contributing to the epidemic.

HIV has gained the biggest foothold in poor countries with rising unemployment and declining health and educational services. Over the past 20 years the World Bank and the International Monetary Fund have conducted a massive social experiment in poor African countries. It is called structural adjustment and has encouraged privatisation of industry, such as Zambia's copper mines, increased unemployment, cut food subsidies, and introduced charges for health and education. The ideology of structural adjustment has recently been repackaged and renamed poverty reduction strategy and programmes with the intention of giving countries ownership of reducing poverty. But the basic macroeconomic programme is not for discussion.

Africa urgently needs a realistic evaluation of the continuing effects of debt and neo-liberal economic prescriptions on the health of its people. It also needs increased aid. The Global Fund for AIDS, Tuberculosis, and Malaria must be supported by new money: the United Kingdom's pledge of £75m ($108m; 123m) is to be taken from money already earmarked for aid. The money must be used to boost health services as a whole. AIDS will not be controlled in the long term by antiretroviral drugs, or even by a vaccine, without examination of the wider social, political, and economic factors that create disease and conditions of risk.

We all have AIDS

EDITOR—In Editor's choice for the theme issue on global AIDS I would replace “granddad” with “President X.”1 Then I would answer the question on behalf of too many African presidents: “I held conferences, I addressed the United Nations, I complained vociferously about the large international corporations who denied us drugs, I formed committees and commissions and advocated tirelessly. But now I realise that instead of asking everyone else to give, I should have given first. I should have held their hands and shaken fewer hands. I should have spent less money on arms and more money on drugs, less money on soldiers and more money on nurses, less money on buildings and more money on people.”

Big pharmaceutical companies are run by businessmen who are very good at what they do. African countries are run by politicians who aren't. How can I look Richard Sykes in the eye and demand free drugs from some morally superior point of view, when I cannot look President Obasanjo of Nigeria in the eye and ask him why he is willing to spend more building the country's second national stadium than he is willing to allocate as its health budget? In May 2001 Nigeria agreed to purchase enough antiretroviral drugs from Cipla, India, to treat 15 000 people (for an unspecified duration). To this day not one tablet has been dispersed. Had GlaxoSmithKline given the drugs for free, I think that we can safely assume, that they would still be sitting at the port … expiring.

Pasteurised human breast milk should be considered

EDITOR—McIntyre and Gray discussed how to reduce the transmission of HIV from mother to child.1 In Oshakati, northern Namibia, we are being ravaged by HIV. At least a third, maybe half, of the mothers delivering here are infected with the virus. Every day in our paediatric wards infants are dying of AIDS; prolonged courses of expensive intravenous antibiotics have little or no effect. Each day that we delay implementing the short course perinatal antiretroviral treatment we are denying the possibility of life to another handful of children.2

A recurrent stumbling block to implementing the programme has been agreeing a policy of what advice we should give regarding the best method of feeding. The population here is largely rural, most have no running water in the home, and few can afford formula feeding. Breastfeeding rates are exceedingly high and probably remain the best option for most infected mothers. But in attempting to give an informed choice in infant feeding methods, the information that breast milk can transmit the virus to the baby dissuades some from what statistically is the safest method.

At the risk of complicating matters further, let us remember an alternative: pasteurised human breast milk. A simple method has been described that could be employed in every home.3 A bottle of milk can be effectively pasteurised by standing it in a pan of water that has been brought to the boil, providing an economical and possibly safer alternative to either breast or formula feeding. In combination with antiretroviral treatment at birth a well supported, well motivated family would, in theory, be able to offer their child chances of survival approaching those of one born in the developed world. This warrants a large scale trial to explore the feasibility of such a method.

Heterosexual transmission of HIV in Africa is no higher than anywhere else

EDITOR—According to Lamptey, in Africa slightly more than 80% of infections are acquired heterosexually.1 The high rates of heterosexual infection in Africa have been generated by actuarial models and antenatal data.2 These high rates are not supported by data originating from prospective epidemiological studies.

In 1997 Padian et al published the results of a 10 year study on heterosexual transmission of HIV in northern California.3 The data were divided into two parts, cross sectional and prospective. From the cross sectional study it was estimated that infectivity for male to female transmission is low, approximately 0.0009 per contact, and approximately eight times more efficient than female to male transmission. Using this estimate of male to female transmission, it would take 770 or 3333 sexual contacts respectively to reach a 50% or 95% probability of becoming infected. If sexual contact were to take place repeatedly every three days this would require a period of 6.3 and 27.4 years respectively. Based on the estimate of female to male transmission by Padian et al it would require 6200 and 7 000 contacts and a period of 51 and 222 years, respectively (table).

In 2001 a community based study was reported from Uganda, where 174 monogamous couples, in which one partner was HIV-1 positive, were retrospectively identified from a population cohort involving 15 127 people.4 The probability of transmission per sexual contact was 0.0009 for male to female and 0.0013 for female to male respectively (table). The authors concluded that the probability of HIV transmission per sex act in Uganda is comparable to that in other populations, suggesting that infectivity of HIV subtypes cannot explain the explosive epidemic in Africa (R H Gray et al, eighth conference on retroviruses and opportunistic infections, Chicago 2001). In other words, there is no more heterosexual transmission of HIV in Africa than anywhere else, including Britain, the United States, Australia, and Europe.

Important facts about global fund were missed

EDITOR—The editorial by Yamey and Rankin on AIDS and global justice refers to the Global Fund to fight AIDS, Tuberculosis, and Malaria and made many points with which we agree but also missed some important facts about the fund.1

In a period of about one year the global fund has evolved from an idea into a reality. The fund has raised US$1.9bn (2.2bn; £1.3bn) to date, and will soon provide hundreds of millions of dollars to innovative national programmes serving people living with, affected by, and at risk for, HIV/AIDS, tuberculosis, and malaria.

This is only a start. The fund will, however, never be sufficient on its own to address these three health problems. That will take a long term commitment on the part of developed and developing nations alike. The fund was never envisioned as the sole source of financial support for efforts to combat these health problems but as a new tool to attract, manage, and disburse resources beyond what is already being spent.

For 2002 the World Health Organization's projected spending on these three health problems amounts to $1.6bn without the global fund. The global fund has the possibility to increase the resources available with $800m, which would mean a 50% increase. The global fund is an independent, public private partnership, and our board includes donor and recipient country governments, multilateral agencies, non-governmental organisations, and representatives from the private sector. The full involvement of each of these stakeholders represents an unprecedented level of shared commitment to address these epidemics.

Yamey and Rankin incorrectly asserted that a member of the pharmaceutical industry sits on the board of the fund in a voting position. In fact, Rajat Gupta, managing director, McKinsey, agreed to assume the position of representing the private sector on the board.

The principles of accountability and action that are central to the global fund are reflected in the transparency of its processes. The fund operations, including the process in which proposals are reviewed and the mechanism of disbursement, were discussed and approved by the board of directors at the January meeting. The fund's decisions will be country driven, with decisions on proposals for submission to be made nationally. An independent technical review panel has been established to review proposals and make recommendations to the board.