Six months of South African TB activism

Whenever a major HIV and TB conference takes place in South Africa, one has come to expect a significant activist presence — and at least under the current minister of health — engagement. With groups like the Treatment Action Campaign (TAC) — arguably the most renowned treatment activist organization since ACT UP New York — and its natural allies, Médecins sans Frontières (MSF) and Section 27 (the legal wonks formerly known as the AIDS Law Project), activism and campaigns are sometimes as much on show as the clinical science — and often far more impactful.

After all, the very first global march for TB education, prevention, treatment and cure was held at an international TB conference (the Union’s) in Cape Town, in November 2007. The focus this year is likely to be more domestic — but what happens in HIV and TB in South Africa is of global significance.

In fact, over the past several months, in the run-up to the 3rd South African TB conference being held this week in Durban, South Africa, activists have been busy tackling several issues that could be critical to more effective TB control in the country.

Revising South Africa’s patent law/intellectual property (IP) policies — which at present are part of the reason why the country is paying far more than it should for many medications, including exorbitant prices for second-line TB treatment (ZAR 24,000 per course) as well as cancer drugs and other essential medications. The activists argue that the country’s patent law should be adapted to take advantage of the flexibility built into international trade law that allows countries to take “measures to protect public health... and… promote access to medicine for all.”

Multiple partners within the South African government have been working together to review the country’s intellectual property policy, while the portfolio committee on trade and industry in parliament has also been reviewing intellectual property across the board to put together an intellectual property policy. Unfortunately, the process has been less than transparent; reports are mixed on what sort of policy is being developed — and there are indications that the US government has been trying to influence the process in favour of maintaining strong protections for intellectual property.

During an interview with HATIP, Mara Kardas-Nelson of MSF noted that the country’s internal policies are inconsistent with the positions it takes on the global stage. “South Africa, internationally, keeps saying things like developing countries need [to be] supporting TRIPS flexibilities and local production and access to medicines in order to adequately address health needs,” she said. “At the World Intellectual Property Organisation (WIPO), they’ve actually led the African Group and Development Group in putting together a position asking for clarification from WIPO on the impact of using TRIPS flexibilities, and practical implementation advice for countries hoping to implement TRIPS flexibilities.  So the country does all of these great things on the international stage—then on the national stage, the exact opposite is happening, where policy makers in the country really push back against advocacy to implement TRIPS flexibilities.”

Why the South African government would choose to limit its options to import or produce affordable essential medications given the public health needs faced by the country — and the government’s constitutional obligation to provide access to health care services — is unclear. However, there is a tendency among some smaller resource- constrained countries in the region to voluntarily go along with US and EU efforts to adopt stronger IP protections than required by international trade agreements. “It’s like there’s this notion of needing to be pro-IP in order for development basically,” Kardas-Nelson told HATIP.

The activists have launched the “Fix the Patent Laws” campaign to increase awareness of the issue and encourage the South African government to stand up for its rights — just as Brazil, India and China (its partners in BRICS) have done. To support the campaign, TAC and MSF have held day-long training events for the media. TAC, represented by Section 27, has become involved in a patent dispute over a generic cancer drug, asking the South African Supreme Court to consider the constitutional right to access to health care services in its decision. They have also published a briefing document online explaining the different legal flexibilities available to South Africa that could be used to reduce costs and increase access to lifesaving medications. There is also a blog for the campaign at http://www.fixthepatentlaws.org/.

Prisons: Activists are also demanding that the South African government remedy the horrendous living conditions, non-existent infection control, poor access to timely diagnosis and treatment that have turned South Africa’s prisons into engines for TB transmission. Not only is such negligence and injury to prisoners’ health a violation of the South African Constitution and prisoner’s human rights, it is bad public health policy as these often undiagnosed and untreated individuals could unwittingly spread the infection once back in their communities.

Details of just how bad conditions were in one South African corrections facility, Pollsmoor Prison Complex, came to light after a court judgement against the facility in favour of a man who probably contracted TB while awaiting trial in jail (for a period of almost five years). Subsequently, a mathematical model published in the South African Medical Journal calculated the risk of TB transmission in the facility to be 90% in one year.

Xpert MTB/Rif access: Activists are challenging Cepheid, the manufacturer of the Xpert MTB/Rif test (and the GeneXpert equipment it is performed on) to reduce the price of the test from the current $17 per cartridge (test) down to $7 per cartridge; and for the government and National Health Laboratory Services to take steps to reduce the other costs associated with importing and implementing the test.

An open letter to Cepheid stating the activist demands can be found here. Midway through the conference UNITAID announced a financing deal that will bring the price per cartridge down to $10. More on that later.

Compassionate access to bedaquiline: Advocates are pressing the South African Medicines Control Council and Ministry of Health to expedite compassionate use access in South Africa for bedaquiline (TMC207), one of the new experimental TB drugs which is furthest along in clinical development, for people with extensively drug-resistant TB (XDR-TB) and pre-XDR-TB. Bedaquiline — a potent anti-TB drug that people with drug resistant TB should be fully susceptible to since it comes from a novel class of drugs — may be the only way to save a person with XDR-TB or pre-XDR-TB’s life when combined with the person’s remaining salvage therapy options (which may not be adequate on their own). It is already available on compassionate use in several other countries — but officials in South Africa appear to be dragging their feet.

An open letter to the MCC on the issue is posted here.

These issues represent just the tip of the iceberg of what is being discussed at the conference this week — starting at the Symposium on Tuesday, hosted by TAC, MSF, Section 27 and Oxfam.

Visit the HATIP Archive.