A Partnership against AIDS in Africa

For two days last November, The Harvard AIDS Institute brought more than 200 people together to forge a paradigm for intercontinental action against the epidemics of HIV and AIDS. Dignitaries and decision makers, heads of state and analysts, and researchers, community organizers, and persons living with HIV gathered at the American Academy of Arts and Sciences, in Cambridge, Massachusetts, from points across Africa and the United States to discuss and debate. In the end, they created a document that spells out the responsibilities the participants deem vital to a fruitful, long-term, collaborative effort against the epidemic in Africa.

The summit, called “Africa Now! A Leadership Summit to Define African Priorities for AIDS,” provided participants a venue for exploring what is known and what is needed in Africa in the areas of prevention; treatment; care and support of orphans, families, and communities; and action and activism. While overviews and discussant panels brought key players to the table for each of the sessions, active participation by all attendees provided the core of the summit. For key to this gathering was the knowledge that while a partnership between Africa and the United States against the epidemics of HIV and AIDS in Africa is indeed necessary, it will be sufficient to the task only if it is rooted in and directed by the people of Africa.

“By now we all know the tragic story,” said Richard Marlink, executive director of the Harvard AIDS Institute, in his opening remarks to the many distinguished participants in African delegations. “Now let’s figure out what we can do about it.”

Kgosi Seepapitso IV (left), Botswana’s ambassador to the United States, talks with another guest at the reception that opened the “Africa Now!” summit. Photo by Sebastian Nichols

Genesis of an Idea
The notion for crafting an Africa–United States collaboration that would approach anew the crisis in Africa had its first glimmerings in January 2000, when the United Nations Security Council convened to address the AIDS epidemic. This was the first time this group had considered a public health issue as a threat to international security. At the invitation of Richard C. Holbrooke, then the United States Permanent Representative to the UN, the Harvard AIDS Institute sent several delegates to this historic event. One of that number was Maurice Tempelsman, chair of the Institute’s International Advisory Council.

That meeting sparked Tempelsman to urge Institute chair Max Essex and Marlink to create an international forum at which leaders from Africa and the United States could jointly determine what could be done now to combat AIDS in Africa. The result: “Africa Now!,” a forum for addressing and defining African efforts against HIV and AIDS. In a rather short period, this idea had grown to a full-fledged project with financial support from, among others, the Merck Company Foundation, Bristol-Myers Squibb–Secure the FutureTM, Pfizer, and Black Entertainment Television, and with research support from Institute staff.

The Institute’s extensive experience in international collaborative efforts helped considerably in the planning of the summit. “We wanted to be sure to keep three concepts in mind,” said Kimberly Hensle, manager of educational programs at the Institute. “First, Africans must be in charge. We must work collaboratively with African leaders to determine the priorities for their people and nations. Second, we need long-term commitments. The solutions to this epidemic will only come through long-term committed partnerships between people and organizations in Africa and elsewhere. Finally, any efforts must abide by good public health practice. The Institute is based at the Harvard School of Public Health, and we remain steadfast in responding to the AIDS crisis as a public health issue around the world.”

Participants listen to a panel discussion at the summit. Photo by Sebastian Nichols

Planners prepared several documents for participants’ use during the summit, the most notable, perhaps, being the meeting’s keystone document, “Principles of Collaboration when Confronting the AIDS Crisis in Africa.” This landmark declaration, submitted as a draft for discussion by participants at the summit itself, summarized what planners in Africa and at the Institute saw as key points for the summit. (These documents can be found at http://aids.harvard.edu/africanow.)

Prevention and Treatment: Collaborative Approaches Seen as Key
The need for focused work in areas that have proven to be effective in Africa was the underlying message of those participating in the summit’s “Prevention Now!” session.

“We know there has been a decline in incidence in areas where prevention efforts have been increased,” said Saidi Kapiga, assistant professor of reproductive health at Harvard School of Public Health, “but good data on the explanations linking the two are often not available. Prevention works, but it needs the support of data to get the critical support of the political community.”

The importance of good surveillance data cannot be overstated, said Souleymane Mboup, professor at the Université Cheikh Anta Diop in Dakar, Senegal. “What sub–Saharan nations need is more widespread and consistent surveillance of antenatal clinic attendees and of high-risk groups such as sex workers. In addition, there is a need for virus-specific surveillance that will help identify subtypes and recombinants, help determine the emergence and spread of drug-resistant strains of the virus, and help monitor the natural history and disease progression of different HIV strains. Finally, nations must improve their monitoring and enforcement of successful behavioral interventions.”

To accomplish this, Mboup called for the establishment of “regional centers of excellence.” These centers would serve as foci for African partnerships in building infrastructure, would contribute to the sustainability of multinational programs to confront public health crises, and would provide fertile ground in which equal partnerships between researchers from the United States and Africa could grow.

For participants in the summit’s “Treatment Now!” session, collaborations that would yield viable, sustainable treatments at all levels of care for people living with HIV or AIDS in Africa were key. The levels of intervention called for embraced the basic psychological and social needs of people living with HIV or AIDS and, perhaps most importantly, the need to develop the infrastructure necessary to provide the most advanced treatment available: antiretroviral therapy.

As outlined by participants, comprehensive HIV and AIDS care must include palliative care, psychosocial support, and management services for sexually transmitted diseases. This care should, however, be augmented by intermediate and advanced levels of care that bring such things as access to drugs that prevent mother-to-infant transmission and specialized care for HIV-related diseases. To effect such treatment plans within African nations, noted Awa Coll-Seck, director of the Department of Strategy and Research at UNAIDS, it is essential for governments to conduct situation analyses of their care programs and to develop action plans that they can use to mobilize resources from international organizations.

Survival: Focusing on Those Left Behind
Mobilizing resources to assist the families and communities left behind is an equally vital, but often overlooked, aspect of the epidemic, according to participants in the “Survival Now!” session. Daniel Tarantola, senior policy advisor to the director general of the WHO, said that correcting this oversight will depend upon the actions of international, national, and local leaders. “Leadership must act to reduce stigma and discrimination and to protect the most vulnerable in society from the HIV and AIDS epidemic and its impact.”

Bishop Rubin Phillip, from the Diocese of KwaZulu–Natal in South Africa, addresses participants at one of the sessions of the two-day summit. Photo by Sebastian Nichols

To this end, Tarantola and session participants itemized principles by which responses to HIV and AIDS can be crafted to ensure protection and fulfillment of human rights. According to session members, it is necessary to address gender inequities that have been exacerbated by the epidemic. In addition, prevention, treatment, and research advancements in prevention and care must be made broadly, equitably, and affordably available to all; efforts to address the epidemic must invite active participation by people living with and affected by HIV and AIDS; and national governments, together with civil society, must work to ensure that national and international efforts respond to country and community needs.

Action: More Than a Concept
Suggestions for ways to ensure human rights grew to include suggestions for ways to ensure national rights during the “Action Now!” session. Conference attendees noted that rebuilding African societies devastated by the epidemic is a monumental task that will demand not only logistical changes but also ideological changes. Minister of Health Francisco Ferreira Songane from the Mozambique Ministry of Health, in fact, called for an overhaul in current thinking on the distribution of resources needed for the task. “Why don’t we talk about a ‘new economic order’ for Africa?”

To further new ways of thinking about and achieving a new economic order, conference participants proposed a number of options, including improving access to treatment, prioritizing research and prevention, enacting procedures and programs to control the incidence of sexually transmitted diseases, and preventing mother-to-infant transmission of HIV. Of these, however, access to treatment was foremost in the minds of most attendees. Jeffrey Sachs, professor at the Kennedy School of Government at Harvard University, noted that perhaps the most important change in this area would involve providing African populations with access to the best antiretroviral therapy available, highly active antiretroviral therapy (HAART).

HAART, commonly known as drug cocktail therapy, is composed of multiple antiretroviral drugs. This therapy has shown great promise but is usually only available in countries that have the resources to produce, distribute, and purchase an abundance of antiretroviral drugs. Resource-scarce nations employ, when possible, mono- or double antiretroviral therapies, which have less effective results. If HAART were to become part of the daily treatment routine for Africans living with HIV, its implementation would need to be conceptualized within an African context.

For this to take place, HAART must be viewed as cost-effective in an African setting. According to Sachs, this is a distinct possibility for three reasons. “First, drug costs are falling. Second, HAART extends workers’ lives. Treatment more than pays for itself in wages earned by workers. Third, HAART improves morale, compliance, and support for HIV and AIDS control. Reducing the rate of transmission is the ethical and ecological goal.” Ultimately, participants said, making HAART available would be the first step in reducing the epidemic’s devastation in African countries.

Maurice Tempelsman (left), chair of the Harvard AIDS Institute’s International Advisory Council, and Festus Mogae, president of Botswana, close the “Africa Now!” summit with statements—and actions—that hold promise for partnership against the epidemic in Africa. Photo by Sebastian Nichols

Accountability was another fervently discussed issue at the summit. Many participants believed that the parsimony of wealthier nations has led to some of the devastation in Africa. Indeed, donor communities have some culpability in the propagation of the notion that HAART’s administration and costs make its use implausible in an African context.

Most participants indicated that multimillion-dollar loans offered by some international banks were nowhere near large enough to handle the lack of resources in their nations. Some leaders suggested that resource-rich nations should forgive debts to resource-scarce nations affected by HIV and AIDS, given that most African nations are not economically prepared to handle such loans in the face of declining standards of living and weakened workforces.

Although the summit spawned an abundance of suggestions for addressing the epidemic in Africa, perhaps the one heard most often was to change current ways of thinking about the epidemic. It is vital, participants said, for the world to accept the idea that an investment in the fight against the epidemic in Africa is an investment for the future of humanity.

Ideally, “Africa Now!” will serve as the start of a campaign with this and other far-reaching and long-lasting effects. And it must be a campaign grounded in unity of purpose, for, as Hage Geingob, prime minister of Namibia said to the gathered participants, “HIV and AIDS recognize no boundaries, no race, no age, and no gender. It is therefore our common problem, requiring that all of us join hands to combat this scourge.”

—Ann Menting is editor of the Harvard AIDS Review; Andrea Shafer is editorial assistant for the Harvard AIDS Review.