- Email: [email protected]
Combating the AIDS pandemic
CORRESPONDENCE
this assumption is the fact that this class of drugs is known to be associated with haematological complications,2 that aplastic anaemia occurred within 3 months of starting clopidogrel, and that no other cause of aplastic anaemia was identified. The only drug that might have been implicated is allopurinol. which was started at the same time as clopidogrel and has been associated with aplastic anaemia.3 Brigitte Meyer, Thomas Staudinger, *Klaus Lechner Division of Haematology, Department of Medicine I, University Hospital of Vienna, Waehringer Guertel 18–20, A-1090 Vienna, Austria 1
2
3
Trivier J-M, Caron J, Mathieu M, Cambier N, Rose C. Fatal aplastic anaemia associated with clopidogrel. Lancet 2001; 357: 446. Love BB, Biller J, Gent M. Adverse hematological effects of ticlopidine: prevention, recognition and management. Drug Safety 1998; 19: 89–98. Conrad ME. Fatal aplastic anemia associated with allopurinol therapy. Am J Hematol 1986; 22: 107–08.
Combating the AIDS pandemic Sir—Amir Attaran and Jeffrey Sachs (Jan 6, p 57)1 prove with statistics what we already know—that the international aid effort against AIDS is insufficient. However, their suggested solutions to this situation are naïve. I have worked extensively for various donors and AIDS service organisations in less-developed countries for 10 years, trying to increase aid to stem the HIV and AIDS pandemic, and I am appalled that Attaran and Sachs’ suggestions might be acted on. Donors alone do not set countries’ priorities. Priority-setting involves donors, governments, and civil society. If priorities are to be decided only by recipient countries, who is to participate in the process and how is genuine inclusion to be assured? Attaran and Sachs are naïve to think that, for example, the Government of Zimbabwe’s priorities for aid expenditure will accurately represent the interests of people vulnerable to HIV and AIDS. Similarly, the idea that the Government of Kenya will accurately assess its implementation capacity to control HIV and AIDS is wrong. Furthermore, to suggest that panels of independent advisors under the management of UNAIDS, not donors, should be responsible for resource allocation is unrealistic. Development assistance is publicly funded, and its allocation should be decided by the public from whose taxes
THE LANCET • Vol 357 • May 5, 2001
the money is drawn. Where do Attaran and Sachs propose to find members for such panels, and how will they ensure their independence? How will this procedure ensure resources are allocated to innovative AIDS-control efforts, such as the development of an AIDS vaccine? Do Attaran and Sachs believe that donors’ decisions to fund, or not, AIDS projects are completely uninformed by people already employed by donor agencies? I could go on. There are three ways to achieve Attaran and Sachs’ objective. First, information about what does and does not work in AIDS control, and why, should be shared between countries affected by AIDS. Such collaboration would stimulate development of proposals for effective projects. Second, investments in technical assistance to develop fundable proposals for AIDS control and care interventions need to be increased. Furthermore, money is needed to fund potential long-term solutions, such as vaccines. Finally, support from political leaders in affected countries is needed. These three practical solutions will do more to increase development aid for AIDS than adding more UN-managed bureaucracy to the process.
many students have web access. Once educated to a high degree of competence, students would learn communication skills to allow them to return to the schools from which they received their secondary education and pass on appropriate knowledge and skills about AIDS to peers. The Youth AIDS Project is supported by academics with enthusiasm, and senior faculty management have endorsed the project with their names. Research projects are being prepared to test the efficacy and outcomes should the project ever come to fruition. The project is proposed by one of the most affected countries5 with the fastest growing HIV-positive rate in the world. We would welcome the most stringent peer review and audit. Despite this, the Youth AIDS Project is in danger of being shelved because we have no funding. Here is a good idea with academic backing that cannot get up and running because of lack of finance—the primary constraint on progress against AIDS. Athol Kent 28 Palmyra Road, Claremont 7708, Cape Town, South Africa (e-mail: [email protected]) 1
Cliff Lenton LentonGROUP, Willis Farm, Cadeleigh, Tiverton EX16 8HU, UK 2 1
Attaran A, Sachs J. Defining and refining international donor support for combating the AIDS pandemic. Lancet 2001; 357: 57–61.
Sir—Amir Attaran and Jeffrey Sachs’ report1 is an example of the high profile given to the research, moral,2 political,3 and financial4 features of HIV and AIDS. Despite the intellectual endeavour, moral reasoning, and political posturing, there remains a financial reality: the delivering of money to the right places, especially in Africa. The Youth AIDS Project was started as a result of the Durban AIDS 2000 conference. Prevalence rates, forecasts, and economic models all suggest that education leading to behavioural change is the best weapon in reducing the spread of HIV. Young HIVnegative Africans need to be able to protect themselves from the disease; HIV-negative status needs to be perceived as a valuable asset. The Youth AIDS Project aims to educate and empower schoolchildren. The plan is to inform medical students early in their syllabus about HIV and AIDS by use of CD-ROM and the internet. All eight South African medical schools have computer laboratories and
3
4
5
Attaran A, Sachs J. Defining and refining international donor support for combating the AIDS pandemic. Lancet 2001; 357: 57–61. Mofenson LM, Mcintyre JA. Advances and research directions in the prevention of mother-to-child HIV-1 transmission. Lancet 2000; 355: 2237–44. DeCock K, Shaffer N, Wiktor S, Simonds RJ, Rogers M. Ethics of HIV trials. Lancet 1997; 350: 1546–47. Horton R. African AIDS beyond Mbeki: tripping into anarchy. Lancet 2000; 356: 1541–42. Editorial. Grants, not loans, for the developing world? Lancet 2001; 357: 1.
Sir—Amir Attaran and Jeffrey Sachs1 underscore the need for an increase in international support for countries devastated by HIV and AIDS. However, their recommendations need to be supplemented to generate long-term answers to the pandemic. Thailand, Uganda, and Senegal have made exemplary efforts to respond to HIV and AIDS, which have led to some reductions in HIV prevalence rates. Nevertheless, to sustain prevention approaches over time is difficult. In most countries, maintenance of the political and social mobilisation needed to hold on to limited gains in controlling communicable diseases is not easy once the public-health crisis begins to diminish. As HIV drugs improve, medical costs will rise. This pattern arises because, although new treatments reduce mortality rates, they require sustained
1447
For personal use. Only reproduce with permission from The Lancet Publishing Group.
this assumption is the fact that this class of drugs is known to be associated with haematological complications,2 that aplastic anaemia occurred within 3 months of starting clopidogrel, and that no other cause of aplastic anaemia was identified. The only drug that might have been implicated is allopurinol. which was started at the same time as clopidogrel and has been associated with aplastic anaemia.3 Brigitte Meyer, Thomas Staudinger, *Klaus Lechner Division of Haematology, Department of Medicine I, University Hospital of Vienna, Waehringer Guertel 18–20, A-1090 Vienna, Austria 1
2
3
Trivier J-M, Caron J, Mathieu M, Cambier N, Rose C. Fatal aplastic anaemia associated with clopidogrel. Lancet 2001; 357: 446. Love BB, Biller J, Gent M. Adverse hematological effects of ticlopidine: prevention, recognition and management. Drug Safety 1998; 19: 89–98. Conrad ME. Fatal aplastic anemia associated with allopurinol therapy. Am J Hematol 1986; 22: 107–08.
Combating the AIDS pandemic Sir—Amir Attaran and Jeffrey Sachs (Jan 6, p 57)1 prove with statistics what we already know—that the international aid effort against AIDS is insufficient. However, their suggested solutions to this situation are naïve. I have worked extensively for various donors and AIDS service organisations in less-developed countries for 10 years, trying to increase aid to stem the HIV and AIDS pandemic, and I am appalled that Attaran and Sachs’ suggestions might be acted on. Donors alone do not set countries’ priorities. Priority-setting involves donors, governments, and civil society. If priorities are to be decided only by recipient countries, who is to participate in the process and how is genuine inclusion to be assured? Attaran and Sachs are naïve to think that, for example, the Government of Zimbabwe’s priorities for aid expenditure will accurately represent the interests of people vulnerable to HIV and AIDS. Similarly, the idea that the Government of Kenya will accurately assess its implementation capacity to control HIV and AIDS is wrong. Furthermore, to suggest that panels of independent advisors under the management of UNAIDS, not donors, should be responsible for resource allocation is unrealistic. Development assistance is publicly funded, and its allocation should be decided by the public from whose taxes
THE LANCET • Vol 357 • May 5, 2001
the money is drawn. Where do Attaran and Sachs propose to find members for such panels, and how will they ensure their independence? How will this procedure ensure resources are allocated to innovative AIDS-control efforts, such as the development of an AIDS vaccine? Do Attaran and Sachs believe that donors’ decisions to fund, or not, AIDS projects are completely uninformed by people already employed by donor agencies? I could go on. There are three ways to achieve Attaran and Sachs’ objective. First, information about what does and does not work in AIDS control, and why, should be shared between countries affected by AIDS. Such collaboration would stimulate development of proposals for effective projects. Second, investments in technical assistance to develop fundable proposals for AIDS control and care interventions need to be increased. Furthermore, money is needed to fund potential long-term solutions, such as vaccines. Finally, support from political leaders in affected countries is needed. These three practical solutions will do more to increase development aid for AIDS than adding more UN-managed bureaucracy to the process.
many students have web access. Once educated to a high degree of competence, students would learn communication skills to allow them to return to the schools from which they received their secondary education and pass on appropriate knowledge and skills about AIDS to peers. The Youth AIDS Project is supported by academics with enthusiasm, and senior faculty management have endorsed the project with their names. Research projects are being prepared to test the efficacy and outcomes should the project ever come to fruition. The project is proposed by one of the most affected countries5 with the fastest growing HIV-positive rate in the world. We would welcome the most stringent peer review and audit. Despite this, the Youth AIDS Project is in danger of being shelved because we have no funding. Here is a good idea with academic backing that cannot get up and running because of lack of finance—the primary constraint on progress against AIDS. Athol Kent 28 Palmyra Road, Claremont 7708, Cape Town, South Africa (e-mail: [email protected]) 1
Cliff Lenton LentonGROUP, Willis Farm, Cadeleigh, Tiverton EX16 8HU, UK 2 1
Attaran A, Sachs J. Defining and refining international donor support for combating the AIDS pandemic. Lancet 2001; 357: 57–61.
Sir—Amir Attaran and Jeffrey Sachs’ report1 is an example of the high profile given to the research, moral,2 political,3 and financial4 features of HIV and AIDS. Despite the intellectual endeavour, moral reasoning, and political posturing, there remains a financial reality: the delivering of money to the right places, especially in Africa. The Youth AIDS Project was started as a result of the Durban AIDS 2000 conference. Prevalence rates, forecasts, and economic models all suggest that education leading to behavioural change is the best weapon in reducing the spread of HIV. Young HIVnegative Africans need to be able to protect themselves from the disease; HIV-negative status needs to be perceived as a valuable asset. The Youth AIDS Project aims to educate and empower schoolchildren. The plan is to inform medical students early in their syllabus about HIV and AIDS by use of CD-ROM and the internet. All eight South African medical schools have computer laboratories and
3
4
5
Attaran A, Sachs J. Defining and refining international donor support for combating the AIDS pandemic. Lancet 2001; 357: 57–61. Mofenson LM, Mcintyre JA. Advances and research directions in the prevention of mother-to-child HIV-1 transmission. Lancet 2000; 355: 2237–44. DeCock K, Shaffer N, Wiktor S, Simonds RJ, Rogers M. Ethics of HIV trials. Lancet 1997; 350: 1546–47. Horton R. African AIDS beyond Mbeki: tripping into anarchy. Lancet 2000; 356: 1541–42. Editorial. Grants, not loans, for the developing world? Lancet 2001; 357: 1.
Sir—Amir Attaran and Jeffrey Sachs1 underscore the need for an increase in international support for countries devastated by HIV and AIDS. However, their recommendations need to be supplemented to generate long-term answers to the pandemic. Thailand, Uganda, and Senegal have made exemplary efforts to respond to HIV and AIDS, which have led to some reductions in HIV prevalence rates. Nevertheless, to sustain prevention approaches over time is difficult. In most countries, maintenance of the political and social mobilisation needed to hold on to limited gains in controlling communicable diseases is not easy once the public-health crisis begins to diminish. As HIV drugs improve, medical costs will rise. This pattern arises because, although new treatments reduce mortality rates, they require sustained
1447
For personal use. Only reproduce with permission from The Lancet Publishing Group.