HIV and AIDS: A Very Short Introduction

The second edition of HIV and AIDS: A Very Short Introduction, by Alan Whiteside, has just been published by Oxford University Press.

HIV/AIDS: A Very Short Introduction provides an introduction to AIDS—the most serious human epidemic in centuries—tackling the science, politics, demographics, and devastating consequences of the disease. The first case was identified in 1981; by 2004 approximately forty million people were living with the disease, and about twenty million had died. The outlook today is a little brighter. Although HIV/AIDS continues to be a pressing public health issue, the epidemic has stabilized. The worst affected regions are Southern and Eastern Africa. Elsewhere, HIV is found in specific, often marginalized populations. Although there remains no cure for HIV, there have been unprecedented breakthroughs in understanding the disease and developing drugs

You can find out more on the Oxford University Press website.

Laurier professor’s leadership builds African-led HIV and AIDS research capacity

News release:

WATERLOO – Laurier professor Alan Whiteside is providing his extensive expertise in HIV and AIDS research to lead a training and mobilization project advocating for African-led scholarship. Whiteside will be the lead researcher on a grant to Laurier from the Bill & Melinda Gates Foundation to build research and publication capacity among African researchers. The grant will support Whiteside’s training and mobilization project advocating for African-led scholarship in support of the African Journal of AIDS Research.

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Writer’s Block

I wish I knew a more productive way of writing than my current style. At the moment it seems that I allow deadlines to creep up on me, and then there is a period of frenetic activity before the article, blog, book or whatever is submitted. I never feel completely satisfied. This is hypocritical, given that the advice I give my students is: “done is good enough”. One thing that became clear over the last few weeks is that I do my best work with other people. I was very fortunate last month in that Gemma Oberth, whose Ph.D. I examined some years ago, and who now lives and works in Cape Town, asked if she could come and spend a period of time writing with me. She was visiting her parents in Toronto and so it was a simple matter for her to travel up to Waterloo. (Having said that though, travelling from Toronto to Waterloo is never a simple matter, the traffic can be horrendous.) This was absolutely great. We were able to settle down, plan out an article, do the research, and actually get close to a final draft. We then exchanged versions over email and submitted it to a journal within a week of her departure. It now goes out to peer review and I will be interested to see what the reviewers think of it. Personally I found this method of writing to be easier than most.

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Convocation and More

Every academic establishment goes through the rewarding period of convocations when degrees are conferred on successful students. Wilfrid Laurier is no different, though here in Canada, there is a tendency for shorter ceremonies over a longer period. For about a week, there are two ceremonies a day, one in the morning and one in the afternoon. I was pleased to be invited to give the convocation address at one of the events. It is reproduced below. I spent a great deal of thought over it, trying to work out the pitch of the presentation, what was really important, and what the students might even recall. The addresses come before they have to walk across the stage and receive their degrees so I suspect most are not paying close attention. I hope you find it interesting. I was complimented by a couple of the students and their parents afterwards so at least I must have reached five or six people.

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Birds and more birds

There are sparrows living in the terminal building at National Airport in Washington. Clearly they have found an ecological niche and are making the most of it. I don’t know if they spend all their time in there or if they manage to get in and out. This is the sort of question that I would ‘Google’, but I was unable to connect with the internet. I was too tired to do battle with the technology, especially since I had just 40 minutes before boarding my flight to Toronto. Instead I sat in the boarding area and contemplated. There was an elderly gentleman sitting in there playing snatches of music on a French horn. This was designed to keep the waiting passengers amused I think. Unfortunately he was not very good and did not play any piece for long enough. One of the gate staff walked over, plonked himself in an empty wheelchair next to me, and gently rolled himself back and forth in time to the music while texting furiously. These are the vignettes of the departure gate.

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Thanksgiving!

There are many places in Ontario named after English towns. Not far from Waterloo, there is a Norwich and down the road, the small town of Stratford hosts, perhaps predictably, an excellent Shakespeare festival. The other day I told a colleague I needed to leave the meeting we were at: I was travelling to London.

“Oh”, she responded, “So am I”.

The difference was she had to drive for an hour while my journey was to Pearson Airport, Amsterdam, and a connection to Heathrow.

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What can donors learn from HIV in responding to ebola

Since the first case of Ebola appeared last year, the virus has infected nearly 10,000 people. The epidemic is concentrated in Liberia, Sierra Leone, and Guinea — post-conflict countries with incredibly weak health systems. It stands to have severe health, social, and economic consequences and is arguably the most pressing challenge to global health security the world has faced in decades.

Read the full article…

Domestic Funding For the HIV and AIDS Response

Commentary: Global Fund Observer

There are just two years remaining on the clock for developing nations to achieve the Millennium Development Goals, including Goal Six, targeting the global fight against AIDS, TB and malaria. While some progress in some parts of the world has been made, it looks increasingly clear that the goal – of halting and reversing the spread of HIV; of achieving universal access to treatment by 2010; and of halting and reversing the incidence of malaria and other major non-communicable diseases – will not be met. Click here for the complete article.

November And December Highlights At HEARD

It’s been a few months of intense traveling and presenting research for HEARD staff. I participated in various conferences commemorating the 30th anniversary since HIV and AIDS was first discovered. Below are some of the event highlights and information on forthcoming conferences I will be attending.

2011 Caribbean HIV Conference

The 2011 Caribbean HIV Conference was held in the Bahamas from 18 – 21 November. The focus this year was given to sharpening the focus on HIV in the Caribbean, the region with the world’s second highest adult HIV prevalence. As a panelist at event, I presented What is Realistic ‘Sustainability’ within the Context of a Multi-country Regional HIV Response?: A Perspective from southern Africa. This conference presentation was prepared with the support of HEARD research intern Natashya Pillay and was well received. The key points were that the Caribbean has succeeded in controlling their epidemic and should be commended for this, the price of success is continued vigilance. There is diversity between the countries. One key lesson both ways is to build on regional organisations.

Focal points of the presentation:

  • Background/Introduction
  • An epidemiological comparison of hyper-epidemic countries in the Caribbean and sub-Saharan Africa.
  • Methodology/Experience
  • Sustainability; regional versus multi-country efforts; prevention, treatment and impact mitigation.
  • Results/Good Practices
  • In particular, lessons can be learnt from Swaziland, the sub-Saharan country with the highest adult HIV prevalence rate.
  • Conclusions/Recommendations
  • Efforts need to be concretized and regional integration is a way to achieve this. It will allow HIV and AIDS efforts to be mainstreamed.

Economic Reference Group Meeting (ERG) in Washington

HEARD organised the World Bank and UNAIDS ERG in Washington on 29 and 30 November. This meeting was attended by HEARD researcher Ilaria Regondi and Professor Whiteside. The meeting looked at financing of the AIDS response and the results of the RethinkHIV project.

Guest of the School of Public Health at the University of Alberta

In late November I travelled to Edmonto and was hosted by David Zakus, who is a Professor and the Director of Global Health in the Division of Community and Occupational Medicine Engagement of the Department of Medicine at the University of Alberta.I gave four presentations consisting of two lectures presented to a class of students: Aid for AIDS and Making Hard Choices: Prevention in the Global Crisis; and two public lectures Economics and HIV in Africa: Costs and Consequences and A Safe Sex/No Sex Month: Could it work? Innovative Responses for Preventing HIV Transmission.

AIDS @30 Symposium at the Harvard School of Medical Health- 1 and 2 December

I was also invited as a participant together with other international health leaders, elected officials, scientists, artists and activists. The meeting was convened to reflect on what we have learned from AIDS and how to apply those lessons towards ending the epidemic. There were presentations from among others, Julio Frenk the former Mexican Minister of Health and currently Dean of the Harvard School of Public Health and Anthony Fauci who is the Director of the US National Institute of Allergy and Infectious Diseases. Durban academics were well represented at the event.

Health Systems Workshop at the Wellcome Trust London

This workshop will take place on the 13 and 14 December 2011. This is the UK health funders workshop on health systems research in low and middle income countries.

Swaziland: The Crisis Continues: 5 August 2011

In May 2011 I was asked by the Royal African Society (RAS)2 to prepare a short commentary on the current political situation in Swaziland. There had been an increase in attention towards the country with news of protests and economic decline. The analysis was intended to stimulate discussion on whether political reform was likely.

At the end of July, I spent a few days in the Kingdom. The primary reason was to attend a Governing Council Meeting at Waterford Kamhlaba School but I also took the opportunity to meet with a number of people outside this community. I spent time with the National Emergency Response Council on HIV/AIDS (NERCHA) and presented an update on recent events, including the IAS Pathogenesis Conference.

We were briefed on the Swazi economy; the political situation; and the rule of law. On the basis of all of these meetings, and other observations, I am reporting on the situation. It does not make happy reading. If I were in the prediction business then I would say in the next six months the crisis will reach its peak.

The Economy

The economy is in dire straits and the country is bankrupt. Earlier this year, the International Monetary Fund suggested the government declare a ‘fiscal state of emergency’ and offered support subject to Swaziland following a road map of measures. This would have included laying off staff and reducing government expenditure. The government declined to do this. There was a view that the country would not meet its July 2011 salary bill but it has in fact done so. The civil service and security forces are now under pressure to take cuts in pay.

The country has seen a 60% fall in revenue, primarily because the South African Customs Union (SACU) payments have dropped (SACU members are Botswana, Lesotho, Namibia, South Africa and Swaziland). This was not a surprise. The government, international agencies, donor community and Swaziland watchers have been aware of this expected fall for many years. See for example our brief and longer article on our website. Brief at: www.heard.org.za/downloads/health-expenditure-implications-of-sacus-revenue-volatility-in-blns-countries-issue-brief.pdf.

In early August the King went to South Africa, cap in hand, asking for emergency funding. The country has received R2.4 billion. South Africa has put conditions in place for better fiscal governance (but there are few on democratization, this has caused great unhappiness among South African unions and others). This loan is a stopgap. Until such time as there is good economic governance there will no new investment in the country. At best the economy will slowly contract, with debt rising steadily.

Politics

Swaziland is the last absolute monarchy in Africa. King Mswati III seems oblivious to pressures to reform; the suffering of his people; and does not understand basic economics. Quite how the country operates politically is unclear, even to informed Swazis. It is a nepotistic, autocratic, kleptocracy where the ruling elite treat the national treasury as their own personal bank. The election system of tinkundla is Byzantine and impenetrable. Although there were constitutional reforms in 2006, political opposition remains banned. Nonetheless there are a growing number of protests and the trade unions – possibly with help from across the border – are flexing their muscles.

The Legal Situation

There is a crisis of law and the independence of the judiciary is under threat. Chief Justice Michael Ramodibedi was appointed as Chief Justice by King Mswati. He is from Lesotho and also sits on the appeal court in Botswana. He issued an order preventing anyone from “directly or indirectly” suing the King. He then suspended High Court Judge Thomas Masuku. In a case filed recently with the Judicial Service Commission, the Law Society accused Ramodibedi of sexual harassment. The Judicial Services Commission banned Swazi press from publishing details of the complaint.

There is an excellent source on Swaziland at: http://swazilandcommentary.blogspot.com.

What Does this Mean for HIV/AIDS?

Swaziland has the world’s highest HIV prevalence. In the last ante-natal clinic survey 42% of women tested were HIV-positive. The 2006 Demographic and Health Survey (DHS) found that 26% of all Swazis between 15 and 49 years were infected; among men prevalence was 20% and among women 31%. Overall HIV population prevalence was 18.8% across the nation meaning about 200 000 Swazis are infected. The response, coordinated by NERCHA, ironically is one of the country’s few success stories.

NERCHA was created through an Act of Parliament, in 2001 under the Prime Minister’s office. It is charged with coordinating and facilitating the HIV/AIDS response and implementation of the national strategic plan. Its main sources of funding are government and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, and it acts as a conduit. The second major source of funding in the country is the US government. PEPFAR provided $38 million in the 2011 financial year.

The exceptional measurable progress is that approximately 70% of those who should be on anti-retroviral therapy are receiving the drugs. This is 65 000 of 84 000 people and therapy is administered at the 350 or lower CD4 cell count level which is extremely impressive. There has been great success in the area of prevention of mother to child transmission. Approximately 97% of women visit the ante-natal clinics, and 85% of those who need drugs are started on therapy. Prevention has been slow to show results. There is a major programme of medical male circumcision with over 30 000 men circumcised in the last three years. Various other initiatives are also in place.

Threats

The lack of government money means that NERCHA’s funding is under threat. They asked for E63 million3 for the April 2011 to March 2012 financial year. They were allocated E47 million (about E4 million per month). For the four-month period ending 31 July 2011 they have only received E4 million of the E16 million allocated. There is no indication as to when, or indeed if they will get the next subvention.

Swaziland was unsuccessful in its last Global Fund bid. Globally there are concerns about US funding. The US House of Representatives Appropriations Subcommittee Bill would cut 9% from current global health funding levels and 18% from President Obama’s FY2012 budget request. It is not clear how this will operationalise in Swaziland.

The Ministry of Health is charged with implementation but government is creaking and it is unclear as to how sustainable the response will be.

Conclusion

As early as 1993 we were warning of the potential social and economic consequences of this epidemic for Swaziland. While it has taken longer than anticipated, the AIDS epidemic in combination with the failure of governance and economic contraction means Swaziland faces a bleak future. Ironically the glimmer of hope is in the response to HIV and AIDS where civil society is powerful and the receipt and disbursement of outside funding is efficient and honest.


1Alan Whiteside grew up in Swaziland and maintains close links with the country. He has written extensively about Swaziland, and is working on a book The Political Economy of Swaziland intended for publication in early 2012
2The RAS undertakes research, analysis and host lectures and meetings of African interest. Its website with commentary is African Arguments
3The Swazi Currency the Emalangeni (sing. Lilangeni) is on a par with the Rand, and Swaziland is in a Common Monetary area with South Africa.