ARVs IF POSSIBLE, BUT NOT NECESSARILY

 

Michael Czerny, S.J.

 

In February, AJAN welcomed Franciscans International, represented by Fr. Michael Perry, OFM, and Mr. Yao Agbetse, for a visit and good exchange about Church efforts to combat HIV and AIDS in Africa. Later, Fr. Perry wrote back:

 

“Thank you for the opportunity to meet with you and to learn of your work and that of others who are engaged in the battle against HIV/AIDS. I found your comments about access to ARVs (antiretrovirals) ‘interesting’. You seem to place great emphasis on the caring/receiving/supporting community as the essential and principal ‘therapeutic’ strategy for those living with HIV or AIDS (PLWHA). You played down significantly the ARVs, as if you thought they were not truly necessary as part of a comprehensive, community-based approach to care for PLWHA. What are your particular concerns with regards to ARVs? Are they too costly, too complicated, too sophisticated for people at the grass-roots level? Do you see them creating more problems than they solve? Are they inimical to the formation of supporting and loving communities of faith-hope-love? I am not sure I fully appreciate your stance on the issue of access to essential medicines.”

 

Fr. Perry’s thought-provoking feed-back stimulated me to try and express what I have been learning during three years working with the African Jesuit AIDS Network. I am happy to share my thoughts, and invite dialogue, with readers of AJANews.

 

The first thing to celebrate is that some of the best ARV programmes in Africa are Church-based. For example, the Southern African Catholic Bishops Conference sponsors programmes in South Africa with 6,000 people on treatment, and supports such programmes in Botswana and Swaziland. The director is Sr. Alison Munro OP <amunro@sacbc.org.za>. In the Eastern Deanery of the Archdiocese of Nairobi, a long-running community-based health programme has 3,100 on treatment. The director is Fr. Ed Phillips MM <edwardphillips@usa.net>.

 

And there are, thank God, many other excellent ARV programmes running out of Catholic hospitals, clinics and dispensaries, and enjoying the full support of Church leadership. And God willing, there will soon be many more, all with sufficient funding or supplies to meet the needs of everyone on their waiting lists.

 

HAART (Highly Active Anti-Retroviral Therapy) is crucial in today’s approach to AIDS precisely because, in an eligible patient, it often effectively reduces viral load, increases CD4 cells, and prolongs life. ART is the only thing right now that is reducing the numbers of deaths, and where we can we need to go for that. So I am not opposed to ARVs. I neither regret their roll-out, nor would I if infected refuse to take them.

 

Still, in the promotion of ARVs there are tendencies which I’m wary about, and which need some kind of re-balancing:

1)      embracing ARVs without considering their inherent or attendant problems

2)      focusing narrowly on ARVs without considering other very (more?) important issues

3)      exalting ARVs in such a way as to look down on other good (better?) approaches or remedies

Let’s take each in turn to explore why such tendencies actually counteract some of the good effects of ART. It may be useful to keep in mind that, according to criteria of the World Health Organization, some 12.5% to 15% of HIV+ people are eligible for ARV treatment, and the proportion is probably higher in Africa.

 

1) Inherent or Attendant Problems

 

Given the splendid results, when someone who is very sick begins taking ARVs and comes back to life -- what is known as the Lazarus effect -- it is tempting to embrace this remedy totally and underplay the difficulties. Yet those difficulties, in the challenging conditions of Africa, can make a decisive difference. What are they?

·        Treatment regimens are life-long, complicated and require constant medical monitoring. In many places, medical infrastructure is very weak or non-existent, medical staff unprepared, and/or the capacity for counselling and testing lacking.

·        The cost of the drugs themselves is often prohibitive, and delivering them is only part of the story. If the patient is not to default on treatment, funds are often absolutely necessary for plenty of other needs: lab tests, treatment of related illnesses, transportation to the clinic, food, school fees, and so on.

·        ARVs, like any antibiotic, are toxic and can have side-effects, sometimes unpleasant, sometimes serious.

·        If ARVS are taken inconsistently or incorrectly, resistance will develop. Even when taken correctly, their effectiveness can fail after a while.

·        Many factors -- not only medical but also basic and psycho-social and spiritual -- can and should delay the initiation of HAART in an individual. Since it’s better not to begin taking ARVs too early, what can be offered to HIV+ people before such treatment becomes appropriate?

·        Financial security is key to administering ARVs successfully. Is there a reliable commitment to maintain the needed level of funding? What if the funders discover another priority and become “fatigued”, what happens to those who have begun taking ARVs?

 

So it is clear that ART is only part of a continuum of care and treatment. The very real problems noted above are not reasons to halt rolling out of ARVs, and there are many stories of HIV+ people overcoming huge obstacles to initiate and maintain treatment. But these successes do not mean the problems have gone away. Enthusiasm for ART should not impede serious consideration of the problems.

 

2) ARVs with/without other issues

 

ARVs have proven so successful in controlling the HIV virus and preventing the onslaught of AIDS, that there is impetus everywhere, much of it foreign-funder-driven, to roll-out and scale-up ART programmes. Such famous success, combined with most ample funding, has also succeeded in shifting the entire discussion on AIDS very sharply toward the role of ARVs. As a result, other cultural and strategic issues of huge import to the welfare of Africans seem to have been squeezed out.

 

Culture first: ARVs belong to a Western class of solutions which one can call bio-medical or technological; they belong to the “drug culture” approach to human sickness and suffering. That is not to demonise anyone but to draw attention to the delicate issue of respecting local culture and expectations. “I’ve lived 15 years in six different African countries,” says an American medical missionary, “and have learned that the Western, bio-medical model doesn’t provide all the answers.” In the “African good tradition,” explains a theologian, “medicine needs the communitarian warmth, and this help the patients to get healthy or to be tough in their suffering.”

 

Strategically, once we look closely at the African context, we find that AIDS is part of a bigger picture of malfunction and suffering. It cannot, therefore, be treated in isolation without having unintended negative repercussions elsewhere. Where does ART fit in the shortlist of urgent remedies or solutions given so many other needs like clean water, nutrition, healthcare, primary education, security and work? Under certain circumstances, ARVs do qualify as “essential medicines” but, unfortunately, in most parishes of Africa, such circumstances do not prevail. ART isn’t the only or first or necessarily the most effective way of fighting AIDS. Pastoral care, moral formation for responsibility and prevention, spirituality, and indigenous remedies may be less spectacularly successful in reinforcing someone’s depleted immune system, but when you admit that basic nutrition, food security, clean water, primary health care, affordable universal education, employment, security are undeniably Africa’s top needs, and if you really want to overcome AIDS, it would be reckless to ignore them and insist only on the current bio-medical means of controlling the infection.

 

Yet, under international pressure, the single issue now seems to be how to implant and expand ARV programmes. And all this medical/clinical noise is much louder, and the results more dramatic and immediate, than those of slower, less fashionable, step-by-step efforts to address Africa’s problems in an holistic fashion.

 

Looking at AIDS within the bigger African picture may not be something that Western interests want to do because it raises concern about international injustice and who’s responsible. When in 2000 the South African President Thabo Mbeki said that poverty more than HIV is the real cause of AIDS, he was immediately and mercilessly lampooned by the Western media. “As They See It: The Development of the African AIDS Discourse” (Adonis & Abbey Publishers, 2005 - visit www.adonis-abbey.com) by Dr. Raymond Downing, is a thorough African reading of all this.

 

Church workers in Africa, often close to people in real need and more distant from powerful commercial or political interests, experience African culture and Africa’s problems in a way that relativises the power/charm of ARVs. Maybe this is what Fr. Perry noticed during our meeting.

 

3) The Danger of Discounting other Remedies

 

I started this article by pointing to some excellent ARV projects, treating many thousands of people, run by the Church. But I am sure that Sr. Alison, Fr. Ed and other Church workers who direct such operations join me in putting equal emphasis on the truly therapeutic value of the caring, receiving, supporting community. Along with ART, we need to do everything else that constitutes building the kingdom of God -- including prevention programmes, care for orphans, developing small Christian communities and teaching about our faith. Medical missionaries who’ve been fighting AIDS on the ground for nearly 20 years tell me, “Good pastoral work is the number one way of keeping the CD4 count high and of defeating AIDS.”

 

So to Fr. Michael Perry’s summary question, “Are ARVs inimical to the formation of communities of faith-hope-love?” the answer is no, certainly not. But forming and guiding vital communities is a prior and more demanding task than the relatively straightforward one of distributing medicines. Throughout Africa, you can count more and more parishes which provide many of the following in the struggle against AIDS: prevention, counselling and encouragement of testing, home-based care, support groups, income-generating projects, home visits and prayer and spiritual guidance, care for orphans and widows, education for vulnerable children, support for caregivers, sacraments and prayer services … These services are what parishes and other Christian institutions normally and naturally offer, usually very well. And those who do the work, often indefatigably and with much stress, need a solid sense of confidence in what they are doing, the modest but real self-esteem of those who labour for the Lord and his people.

 

And here the current fixation on ARVs presents a spiritual challenge. I am thinking of all the Church workers and volunteers where ARVs don’t exist and won’t soon. Hearing only about the wonders of HAART, don’t Christian AIDS ministers and their poor clients find themselves tempted to feel that Church-sponsored services are second-best to the wonder drugs? Are they not in danger of under-rating the fine AIDS ministry they do or receive?

 

They certainly have no reason to! Where ARVs haven’t reached, or not yet, Church people should NOT let ARV-induced doubt discourage them. They should not consider their efforts futile or paltry. Bishops and clergy should often and publicly give thanks for the many other good (better?) things that Church people offer to those who are infected and to those who are ill, not to mention those who are affected and to those who offer care. They deserve solid support as well as clear guidance.

 

Church-sponsored ART programmes are usually holistic in their approach and collaborate with others to offer the additional services that the Church cannot offer. But do the bigger, better-endowed ART programmes recognize their own limitations and seek out the Church to complement their medical services with communal and spiritual ones? I think the symmetry is often missing.

 

So, if you were an African Bishop with a very limited budget, and if you could sponsor either primary education or ARVs in your diocese, which would be the more effective way of fighting AIDS?

 

In conclusion, making ARVs available is an urgent issue of international justice, and AJAN joins the Ecumenical Advocacy Alliance in advocating for “universal access to treatment” and supporting “efforts to provide access to essential medicines, particularly anti-retroviral therapies” (please visit http://www.e-alliance.ch/hivaids.jsp). Where human and financial resources and infrastructure permit, let the Church both minister pastorally and offer health-care including ARVs. But in most corners of Africa where Christians simply do what Jesus did -- feed the hungry, preach and educate, visit the sick, pray for healing, accompany the dying, comfort the bereaved, here the Church is waging the primary battle against AIDS.

 

 

Included are the names and e-mails of those involved in asking the question and formulating the response, in case readers would like to contact any one of us: Raymond Downing MD <armdown2001@yahoo.com> and Michael Perry OFM <Mapfran@aol.com>

 

AJANews 43 (April 2006); Hekima Review 35 (May 2006); Points of View 35 (June 2006).