Noted researcher Dr. Tony Barnett of the London School of Economics believes the potential transmission of viral resistance could quickly limit the effectiveness of antiretroviral treatment (ART) in Africa. “Five-to ten-year is the window of opportunity we have,” to find other responses to mitigate the impact of an HIV/AIDS endemic in Africa — which, according to Dr. Barnett “will be with us for the foreseeable future.” Dr. Barnett made these statements during his keynote address at the International Conference on HIV/AIDS and Food and Nutrition Security, held last week in Durban, South Africa.
“The problem is, we don’t know what to do with that 5-10 years. There is an urgent need for innovative solutions,” said Dr. Barnett. But he fears that action could lead in the wrong direction if it is based upon ’simple stories’ – narratives of the epidemic and its impact that have become accepted by policy makers, donors, opinion leaders and the research community.
“We do not have long-term evidence with the kind of detailed analysis which is necessary if we are to understand the complexity and diversity of the impact of the epidemic on rural society in Africa,” said Barnett.
The story of HIV/AIDS in a rural Ugandan village
Dr. Barnett himself helped establish one of the best-known narratives on the effects of HIV/AIDS in Africa. Early in the epidemic, Dr. Barnett evaluated the impact of HIV/AIDS on rural households in Uganda over the course of 1980-89. He observed that Ugandan families were losing their older children to illness, followed by the head of the household and then the mother falling ill. Over this period, farm productivity would fall. In the end, orphans would be left behind to run a child-headed household.
“For quite awhile, it became a story that was accepted as ‘the truth.’ And that story has appeared in various forms over the last fifteen years or so,” said Dr. Barnett.
These stories led to predictions that Africa would experience:
- Labour shortages as a result from the impact of the epidemic on the productive age group
- A progressive decline of agricultural production and food capability
- A reduction of cultivated land area
- A reduction of crop portfolio
- A decay of infrastructure
- Reduced production and productivity
- And possibly, some have claimed, “famine”
“But we don’t have are any long-term studies tracing the effects of HIV/AIDS on rural livelihoods and food security over the last 15 to 20 years,” said Dr. Barnett.
Last year, Dr. Barnett went back to the same Ugandan village where he had worked in 1989.” What he found was unexpected.
“The farming system had not collapsed,” he said, “because there had been a profoundly moving and very strong community response. This is not a devastated community; this is a community where the farming system has remained intact.”
Hard to generalise
“But this is just what happened in one place — in a very resilient farming system,” Barnett continued. “What we don’t know is what has happened in other systems that are less robust. There is probably a diversity of responses.”
Less resilient agricultural systems are probably less able to cope with the impact of epidemic. But little is known about the “stories” from those communities.
Barnett explained that, until recently, there were few studies of how the HIV/AIDS epidemic has been affecting the wide range of rural environment and livelihoods in Africa, including fishing communities or animal herding regions.
But recently, there has been a upsurge in such research and much of the available data on the impact of the epidemic on rural livelihoods was reviewed in a recent meta-analysis (Gillespie and Kadiyala) published by the International Food Policy Research Institute (see www.ifpri.org). Dr. Barnett noted that, “while the analysis found an indication of increasing inequalities in some societies, my reading is that it is actually hard to generalise for all of “Africa” or even “southern Africa.”
He pointed out that it is also hard to isolate the causal influence of HIV/AIDS from other underlying environmental and policy conditions: “The epidemic may be a tipping point factor, but in many circumstances, it may not be the sole reason for the effects that we are seeing. We’re dealing with an extremely complex set of causal links here – which may be different or nuanced from place to place,” said Barnett.
“The challenge,” he added, “is to recognise the diversity and to create large-scale responses that can cope with it.”
“Governments, multilateral agencies, bilateral agencies have great difficulty in dealing with diversity,” said Barnett. “It’s very hard to have large programmes that take into account the complexity of the situation. One size does not fit all.”
Pay attention to the pathogen
Barnett believes a better understanding of HIV virology could help prepare those planning responses to the epidemic.
For example, the average time from infection to AIDS is eight or nine years. Partly, as a result of this slow rate of disease progression, “the epidemic has shown itself to be both too slow and too fast for us to respond,” said Barnett. “It’s so slow that it’s put on the backburner for a long time, and then it moves so fast that by the time you realise what is happening it’s too late to do what you should have done ten years before.”
And viral resistance may limit the effectiveness of our best available intervention: ART. Resistance should be uncommon if effective regimens are administered to motivated individuals who have continuous access to treatment. But a very high rate of adherence is necessary to keep from developing resistance to the drugs.
Dr. Barnett thinks adherence could be difficult in rural areas where access is a problem – especially because treatment centres may be effectively inaccessible to many patients. Furthermore, in remote small communities there can be very little privacy and stigma which could act as a disincentive to adherence.
“How long before we see new epidemics of resistant HIV?” said Dr. Barnett, “and when resistance comes, the big pharmaceutical companies will not respond hurriedly to Africa’s need for a new generation of antiretrovirals — not after their experience with the last generation and the lowering of prices.”
An unprecedented long wave crisis
“HIV/AIDS is not like other emergencies in food and nutrition – it is a long wave event, said Dr. Barnett. “We have to recognise that the entire balance between relief, rehabilitation and development work may have changed – in some communities. Policy, operations and thinking must switch into a new paradigm.”
The disease has altered regional demographics, as well as the local social and economic circumstances in which policies and programmes will be operating. “We have to recognise that institutions on the ground may have short institutional memories,” said Barnett “because people who are resourcing those institutions are younger and dying young. And we need to take into account that the institutions in which we work are themselves affected by the epidemic.”
In addition, when people think that they may have limited life expectancy, it affects the decisions they make. It affects their investments and the effort they put into learning new techniques and new technologies. “How we introduce innovations, responses to the epidemic at a time when people are not living long enough and not healthy enough to adopt innovations?” said Dr. Barnett.
When the Black Death struck medieval Europe, the loss of the work force made new labour saving technologies practical. “But old solutions may no longer be appropriate in the context of changes brought on by the epidemic. For example, prevention has failed miserably in Africa,” said Dr. Barnett. “What happened is that we went for already installed responses, condoms and vaccine development. What we didn’t go for were microbicides, which are a gender specific, woman controlled response. And now, in the third decade of the epidemic, we are just beginning to think seriously about testing microbicides.”
The challenges, according to Dr. Barnett, are to understand the situation (rather than listen to the stories) “because this situation is unprecedented and unknown. We need to engage critically with established narratives.
“We have to consider the appropriateness of known technologies and approaches and think of new and innovative responses to a novel and changing situation,” he concluded.