Part I: Interview with Prof. Alan Whiteside

"This is an edition of the International AIDS Economic Network (IAEN) Global Dialogue Series with Alan Whiteside, D Econ, founder and director of the Health Economics and HIV/AIDS Research Division at the University of KwaZulu-Natal, South Africa. He is one of the Commissioners on the Commission for HIV/AIDS and Governance in Africa, and has written several books on the economics of HIV/AIDS.”

QUESTION 1: How is the fight against AIDS in South African going? What are the key policy issues concerning AIDS that are currently being debated?

ALAN WHITESIDE: The reality is that the fight against HIV/AIDS in South Africa is not going terribly well. The antenatal prevalence is showing a small but steady increase year on year. The 2003 data gave us a prevalence of 27.9% among antenatal clinic attenders this was up from 26.5% in 2002.

Given that the exponential phase of growth in prevalence was between 1994 and 1998 we would expect to see growing number of people falling ill and dying.

In responding to this epidemic there are three areas that we need to engage around. The first is prevention and as indicated it seems that with high prevalence rates we are not doing too well on that. If people are dying then they are being replaced by new infections because we are not rolling out ARVs. The second area which we have to look is providing care and ideally antiretroviral therapy to those people who are infected. Our roll-out in this country has been very slow and even if we hit the target of 53000 requiring treatment this is probably only 10% of those who would benefit from it. The third area of concern is around the impact of this epidemic particularly on children in terms of orphaning and increased poverty.

The key policy issues are rather hard to put one's finger on. The Ministry of Health argues that we have a plan in place and we are rolling it out. But because health is a provincial issue one would have to look at this level and here I think there are variations from province to province.

QUESTION 2: What are the major prevention efforts underway in South Africa? Any successful interventions the world should learn from.

ALAN WHITESIDE: There are two major initiatives that have lessons for the rest of the world and these are Soul City and loveLife . Both of these are prevention efforts and I think that the world can learn a great deal from them but they are not areas where I have particular competence. Both have Websites and I would urge people to look at them. I think the most important lesson globally is that there are no quick fixes.

QUESTION 3: What is the current situation regarding availability of AIDS medications?

ALAN WHITESIDE: The situation is that people who can afford treatment, in other words whose people with money or who are on medical aid schemes, can access private medical care and will be able to get the best treatment available in the world. But you have to be able to pay for it. There is a significant population who can access treatment in this way and it is believed that there are probably 45000 South Africans on antiretroviral therapy in the private sector. This is substantial. There are also a number of innovative schemes for managing care of people with HIV and again Websites can be accessed. As in most countries the majority of South Africans are dependent on the public sector and here we have a problem because although there is a plan to roll-out antiretroviral therapy it has been rather slower than anticipated and currently it is estimated that only 11000 of the 53000 people who should be on treatment are in fact receiving it.

The irony is that South Africa -- with its advanced health care system, the large number of health care workers, and the access to reasonable infrastructure -- ought to be able to roll it out a lot faster and there can be no doubt that there is a degree of frustration among health care workers in this country. I believe it could also be something of a pilot case for what you can do in middle income countries.

Having said that, we do need to be aware of the constraints of infrastructure and staff but there is a wonderful South African saying which is "We will make a plan" and I do believe that we will do so.

QUESTION 4: You promoted the "Free by 5" initiative, what is that?

ALAN WHITESIDE: 'Free by 5' is a declaration which advocates for free access to HIV/AIDS treatment programmes, including drugs and all tests, for all those living with the virus in developing countries. The declaration gives evidence that without free treatment, WHO and UNAIDS will not achieve their target of three million people on anti-retroviral treatment by 2005. There are many problems with imposing user fees for treatment. For instance they lead to poor adherence and drug resistance, and heighten vulnerability to the virus. Co-payment also causes problems in scaling up treatment programmes and achieving equity in treatment delivery. We also note that the contributions from patients are relatively small (around 10% in Senegal for example) so it does not dramatically increase the funds sought from donors. But to the patients the costs are crippling and this obviously limits the number of people accessing treatment. We are calling on UNAIDS and WHO to develop guidelines on free treatment, and we urge donors make treatment free of charge. So far we have had some every influential signatories including Stephen Lewis and Helene Rossert (Vice president of the Global Fund), and a number of economists, policy makers, public health exerts, academics and NGOs have signed up. You can find out more and sign the declaration by visiting our website .

QUESTION 5: What books or reports do you suggest very AIDS professional should have on their desk?

ALAN WHITESIDE: I think that we all need to be up to date on the statistics which means that we all should be looking at the updates provided by UNAIDS. The most recent update came out in November 2004. These are accessible from the Web. Every person working in this field should also know the data from their own country and that means being aware of whatever surveys are going on and also know the context of the epidemic in terms of poverty, access to facilities and so. Most of this data can be taken from the UNDP's Development Report. Working in this field it is also important to understand statistics, virology and epidemiology and unfortunately there is no easy text book which covers all this. The two possibilities are Gerald Stine's book AIDS Update and of course the book I co-authored with Professor Tony Barnett AIDS in the Twenty First Century, published by Palgrave. I feel uncomfortable about recommending my own writing but I do think it is a comprehensive review of many of the issues that people need to understand.

QUESTION 6: At a global level what do we need to do to slow AIDS?

ALAN WHITESIDE: This is a difficult question because it has three responses. There's the response about prevention which must remain a priority in every setting. There's the need to provide care and treatment and there's also the need to look at the impact of AIDS particularly in countries with more advanced epidemics. The reality is that many millions of people have already died and many millions will die. It is incumbent on us to think about what this means for the people who are left behind. So the question as to what to actually do is not all that simple. One has to be aware of the type of epidemic the current status of the epidemic and the society in which one is operating. For example responding to epidemic in, say, Ukraine is rather different from what is needed in, say, Lesotho.