12th World AIDS Conference
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...bridging the gap

LAST UPDATE: Wednesday, 1 July, 1998 18:27 GMT    S U M M A R Y     S E S S I O N S   ...all the news, as it happens
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Summary of Tuesday, 30 June, 1998

Economic aspects
Economic aspects of the HIV/AIDS epidemic refer to utilisation of inpatient and outpatient care, drugs and the costs associated. Economic impact assessment is done for the purpose of cost-effectiveness analysis, where health-care inputs are related to health gains (i.e. prevented transmissions, delayed AIDS cases and gained life years).

  • Highly active anti-retroviral treatment (HAART) appeared to be as an important topic for cost-effectiveness. Increasing use of HAART has been associated with a reduction of inpatient costs.
  • Many studies report major increases in the utilisation and costs of drugs after the introduction of protease inhibitors.
  • More people with HIV/AIDS are receiving anti-retroviral therapy. In France, persons on treatment increased from 60 to 90%.
  • Major problems concerning affordability are reported for developing countries. In India, a study reports that only 2.8% of patients can afford combination therapy.

Bridging session : Implications of therapies for developing countries

  • Given scarce resources, countries have to make choices. If brutal choices are not made now, in the future they will be even more brutal.
  • For many countries, in addition to the fight against AIDS, governments have many other developmental objectives. They are confronted with diseases such as malaria, tuberculosis, other STD’s, and increasingly chronic diseases. Choices have also to be made between different areas of development.
  • According to the World Bank, treating one patient with AIDS is as expensive as giving 10 children primary health education. The list of competing alternatives is almost endless, for example, basic access to water and food, access to primary health care and essential drugs, rehabilitation after internal wars and conflicts.
  • In many regions of the world, opportunistic infections treatments, anti-retroviral drugs, and palliative care treatments are not available.
  • In order to implement any program, there needs to be a stable health services infrastructure, which is lacking in many countries but it is possible to establish a network of services. In Brazil, 58,000 persons take anti-retroviral therapy now. The costs increased from $ 37/mo in 1996 to an estimated $ 600/mo in 1999.
  • Unfortunately many countries set other priorities.
  • Pharmaceutical companies can make a contribution, by lowering the prices :
  • The differences in prices are shameful. In Mexico, AZT costs less than $0,50 while it is almost $7 in Brazil. Intravenous AZT costs $6 in Brazil and almost $50 in Mexico. The costs of triple therapy in different Latin America countries range from $7,000 in Costa Rica to $16,000 in Uruguay.
  • Pharmaceutical companies have mission statements. But words are not enough, where action is needed. Pharmaceutical companies should no longer focus on shareholder-value. Stakeholder-value is tomorrow’s management keyword.

International Funding and Policy

  • The case of Thailand showed how the Asian financial crisis is affecting their National Program and their ability to face the AIDS crisis. The Canadian representative spoke about participating to support international development.
  • Bernard Kouchner, the French health minister, reiterated an important announcement. France is taking the leadership in an effort to create an international partnership with other industrialised countries to help fund antiretroviral medication for poor countries. This proposal has been taken to the European Parliament and to the G 8.
  • Callisto Madavo from the World Bank gave a comprehensive explanation on why AIDS was a development issue. He offered suggestions of what African governments could do to implement more effective policies in the fight against AIDS. He also urged the World to help in the solution.
  • Dr Jonathan Mann presented a very compelling presentation on how prevention continues to be the most important tool against the AIDS epidemic. He argued that the two most powerful prevention agendas today were finding an effective vaccine and creative social change, based on human rights.

Gender and Power
Participants agreed on the importance of analysing the way socially constructed male and female roles are affecting the spread of AIDS.

  • Gender roles are not biologically determined but socially constructed.
  • Gender is the set of norms, prescriptions and cultural representations that a society dictates for male and female behaviour. This varies in different societies, social classes and regions of the world, but in general determines differences of what is expected of men and women and tends to establish both stereotypes for each sex and double moral standards. This is the basis on which much of the inequality between men and women is established.

The projects presented in this session were a very vivid example of how these theoretical principals play out in different countries.

Coping strategies: Individuals, families and organisations
Home care is often promoted as an alternative, particularly in developing countries; but the home is not necessarily the safest place for PWAs. Discrimination also often happens at home. Individuals and their families must receive support in order to create the environment needed by PWAs to improve their quality of life. Organisations develop programs that are often articulated around the following issues:

  • Training and counselling for individuals and their families (including children);
  • Information and discussion on stressful situations in the family;
  • Sex after diagnosis;
  • Care for dependants, children in particular.

Promotion of community coping strategies should NOT mean a simple shift of burden to families and communities. Women can easily be overburdened. They must be empowered in their different roles. PWAs are also potential care givers and agents of change, and their involvement is crucial for the success of coping strategies.

Evaluation Methodology

  • Recommendations included the need to establish clear standards for program evaluation, more consistent publication guidelines, and more studies of this type.
  • Interventions aimed at enhancing evaluation skills in NGOs can improve the delivery of programs.
  • One study compared behavioural with biological indicators of sexual risk. The results suggest that, while self-reported behavioural change may predict risk reduction, it usually does not if measured by objective measures. Another study, focusing on studies of sero-discordant heterosexual couples, underscored the need for more careful exploration of risks and behaviours, and raised doubts on whether all the necessary questions on risky behaviours are in fact being asked in current studies.

HIV Transmission: Infant Feeding
Although vertical transmission through breast milk was identified in 1985, there have been many complex issues surrounding the recommendation of artificial feeding.

  • For HIV-positive mothers, information on artificial breast-feeding is essential since it can prevent the child’s infection. Each woman should have a possibility of informed choice. For artificial feeding to be effective mothers need clean water, the knowledge on the how to sterilise utensils and prepare the formula.
  • The widespread use of artificial feeding by HIV-negative mothers and women unaware of their status can increase malnutrition and mortality. Infant mortality is 16 times more likely with artificial feeding than if a child is breast-fed.

The artificial feeding business should consider:

  • Emphasis on replacement feeding as a medicinal practice;
  • Procuring the formula centrally to control it’s distribution;
  • Arrange for generic packaging so as not to promote the product.

For successful artificial feeding there is a need for education on alternatives such as cow and goats milk, expressing breast milk and boiling it and, if available, the use of an HIV-negative wet nurse. Making the change from the emotional rewarding act of breast feeding to artificial feeding often is an enormous burden for the mother to carry. Comprehensive education, emotional support and access to different options are needed.

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