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FROM THE
THE ISSUE

EDITOR
ADVOCATING ACCESS

Antiretroviral (ARV) therapies are again featured in this issue of
the Journal. The Guidelines for the use of ARV therapy in paedi-
atric practice, formulated by the paediatric subcommittee under
the leadership of Or Lean Levin, are highlighted. These guidelines
are different from those that have appeared elsewhere and are
unique to our setting. The Guidelines were circulated to a panel of
international reviewers and their views were incorporated into
the document. These Guidelines are a companion to the Adult
Guidelines that appeared in the July launch issue of the Journal.
It may be argued that in both instances there has been a focus on
options that are not available to the vast majority of the HIV-
infected people in our country. This may be so, but we would argue
that it is important for our clinicians to be well informed with
regard to the difficulties and complexities inherent in the use of
these drugs. We are witnessing an increasing use of these
therapies in the private sector as more health care funders are
providing benefits to HIV-infected individuals, so it behoves all of
us to keep abreast of developments in this dynamic field of
medicine.

Of equal importance is the article by Mark Heywood of
the AIDS Law Project who urges clinicians to be more vocal in
their efforts to expand access to ARV therapies among their
patients or among the communities they serve. The HIV Clinicians
Society would endorse this stance and urge its members to be
more outspoken on these issues and become advocates of expan-
ded access to quality care. It is realised that combination therapies
do come with a significant price tag, but the cost-effectiveness
of these therapies must not be underestimated. We need only
refiect that in the recent past combination therapies to treat
tuberculosis were deemed unaffordable, but are now freely
available at no cost to the patient. The Society congratulates the
AIDS Law Project on its achievements in protecting the rights of
HIV-infected persons, including the positive outcome in two
recent court cases, that have led to significant changes in
corporate policies for HIV-positive employees or prospective
employees.

The controversy surrounding HIV as the causative agent
of AIDS has once again surfaced in South Africa, gaining political
support at the highest level, including the support of the State
President. This dehate has had widespread repercussions among
scientists, clinicians, HIV-infected individuals and more import-
antly, the general population at large. A response to this situation
was the 'Durban Declaration', which was distributed at the 13th
International AIDS Conference in July 2000 and is published in full
in this issue of the Journal. The Declaration was formulated by a
committee consisting of a number of prominent international
scientists and this document was subsequently circulated to
thousands of scientists and clinicians throughout the world, who
in turn became signatories to the document. This document will
be useful for clinicians in answering the many questions currently
being asked of them by their patients.

DES MARTIN

Editor, Southern Africon Journal of HIV Medicine
President, Southern Africon HIV Clinicians Society

While neighbouring Botswana and other SADC countries and states
have been solicited with offers of free or highly reduced-price
antiretroviral treatments that will bring the cost of HAART to around
US$l 000 for a year of therapy per patient, South Africa continues to
face tough marketeering by the same drug manufacturers, who see
the country as a lucrative market with virtually unlimited need for
their products.

Lack of political support, or infrastructural inadequacies are cited
for the continued refusal of these companies to consider South Africa
as a priority for broadening treatment access through preferential
pricing strategies, while they continue to milk the private sector of
resources in exchange for suboptimal regimens or barely affordable
combinations of therapy. By discounting drug prices only through
guaranteed volumes of sales, these companies ensure that the higher
demand they create among those who somehow manage to pay for
these combination packages, leads to volume-linked profitability. The
pharmaceutical industry continues to extract unreasonable profits in
the developing world for their formulations through 'patent
protection', when the costs of developing these patents are already
being recovered in their primary markets and the costs of producing
the drugs are a fraction of the prices charged.

There is no doubt that poverty both facilitates HIV infection and
exacerbates the progression to AIDS, yet the current solutions being
offered by the Industry will only worsen poverty through their net
effect over time.

Offers from these sources are not benevolent and the countries
contemplating their responses to the offers that have been pre-
sented face difficult decisions that will leave them responsible for the
uncertain long-term consequences and implications.

This could be one of the reasons for South Africa's strong position
within the SADC on defining the framework and conditions for nego-
tiating these deals and for the principled guidelines for countries
participating in the process to have been put forward within the SADC.

Pharmaceutical manufacturers have not been the only busi-
nesses to profit from the epidemic, as Managed Care companies and
other service industries are deriving income for delivering HIV-linked
products and services that are of highly variable value. The same
business models that have been proven over time to make money
have been applied to this 'new market:

This has to change, as the region faces an unprecedented crisis
that cannot be addressed through 'business as usual' approaches.

The West and the wealthy can no longer be allowed to profit
once more from the misfortunes of Africa.

Antiretroviral therapy is life giving, yet it must be sustainable and
effective, as well as being affordable to the households, communities
and countries of the individuals who benefit from treatment. A
starting point is to ensure that a proper, transparent framework of
assistance is created that not only enables treatments to be made
available, but also the means to pay for, distribute, administer and
monitor them.

It is time for the professions and civil society to take issue with
the current status of HIV care access in our region and to become
better-informed participants in negotiations and stronger advocates
for our patients' survival.

SHAUN CONWAY

Managing Editor, Southern African Journal of HIV Medicine
Executive Director, IAPAC Southern Africa

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