France at war against aids
Sub-Saharan Africa is far and away the
part of the world most badly stricken by Aids
with more than 25 million people infected.
A home for children orphaned by Aids,
Kenya.
Although in France the introduction of triple therapies has led to a clear advance in patient care, the epidemic has not yet stabilised, and there is even a tendency for vigilance to relax. In an attempt to remedy this situation, the government is relying on prevention, the foundation, together with access to screening and the support of sufferers, of the national policy to fight Aids. In international terms, France is one of the countries most involved in the fight against the pandemic, in the face of which it advocates a global approach.
More than 36 million people in the world today are living with the Aids virus; almost 22 million have died of it; 13 million children have lost their mothers because of HIV... The litany of figures compiled by UNAIDS, the United Nations agency responsible for the fight against the epidemic, sends shivers up your spine. For the last twenty years, when this viral disease which invades and destroys the immune system was first described, the epidemic has ravaged every continent. However, sub-Saharan Africa is by far the area most affected since, with more than 25 million sufferers, it has 70% of those infected worldwide... in an area with barely more than 10% of the world population.
In France, while the figures are less alarming, the Ministry of Health nonetheless estimates that there are 120,000 persons currently known to be infected; and that there have been 36,000 deaths since the start of the pandemic. Nevertheless, in France there are five times fewer people dying from Aids than in 1996, thanks to the appearance of new treatments: triple therapies. Even so, the epidemic situation has not stabilised: between 4 and 6,000 people are said to become infected each year and, since 1997, heterosexual transmission has predominated. Indeed, the proportion of people infected after homosexual sexual contact has reduced, as has that of injecting drug users. However, the number of women affected has rocketed - in ten years, one woman for every seven men has risen to one for every three.
Prevention: a priority
Virology laboratory in Franceville,
Gabon.
Indeed, the CEFS considers that: "The hope aroused by advances in treatment and the perception of an epidemic under control seems to be leading to a fall in vigilance which may have consequences on prevention behaviour, with the risk being perceived as lesser."
Yet while the length and quality of life of sufferers has greatly improved and multiple therapies rapidly reduce viral particles in the blood to an undetectable level and partly restore the immune system at every stage of the illness, this should not obscure the fact that these treatments are highly toxic, have major side effects and are difficult to manage from day to day. Moreover, 6% of patients do not respond to treatment.
To remind people of the permanence of infection and the gravity of the disease and to encourage the adoption of risk avoidance behaviour for oneself and others (such as wearing a condom, especially in cases where there are several partners, still more as concerns polygamists), the CEFS has set up a three year programme combining campaigns directed at the general public and actions targeted at priority groups, with the support of special interest media, local groups and intermediaries from communities.
Women at greater risk
"Use a condom,
the only way to prevent Aids".
An information poster in Abidjan,
Ivory Coast.
To physiological factors are added cultural and social factors that contribute to contamination (inequality between men and women, the latter still all too often expected to take responsibility for preventing the risk of Aids, as they are for preventing pregnancy, violence, financial insecurity and social exclusion). Amongst other social groups targeted are practicing homosexual men, injecting drug users, migrants, people with little access to information and the young.
To permit diagnosis and care of people before the symptoms of the disease appear is one of the priorities of the Ministry of Health. One person in two discovers they are HIV positive either when Aids is diagnosed or when they consult a doctor about an opportunistic illness.
Yet it is now possible to establish a biological diagnosis of infection within two weeks after a risk has been taken (unprotected sexual intercourse, a split condom, injury from a blood-soiled object, sharing syringes when injecting), which permits early care. Preventive treatment (one month’s multiple antiretroviral treatment) can also be offered within forty-eight hours following exposure to the risk, in an attempt to prevent contamination.
Since 1988, to make access to screening easier, the government has set up in each French Département, anonymous and free screening centres staffed by multidisciplinary teams (doctors, nurses, psychologists, social workers) where information and advice is also given
Progress in the fight against the disease, both in terms of the health, psychological and social care of sufferers and their families and friends, and of research, could however, never have been achieved without the extreme mobilisation of civil society and the tenacity of organisations such as Act-Up, Aides, Arcat-Sida, Ensemble contre le sida [All Against Aids] (run by sufferers themselves) and Médecins du monde. These organisations have also changed the way victims of HIV are perceived, especially by fighting the discrimination to which they were subject as well as actively involving them in the patient-carer relationship.
Journalist
Representative of Charles Josselin, Deputy Minister of Cooperation and the French-speaking World, Anne Dux underlines the special nature of the French approach on the subject of international solidarity in the fight against Aids. An approach which is determined to be resolutely global.
Label France: I n what respect has France been a pioneer in the matter of co-operation in the fight against HIV?
Anne Dux: Its concern in this field is long-standing since it dates back to 1985. Gradually, we have become interested in all ways of fighting Aids: education, training, prevention, the safe blood transfusion, screening, mother-child transmission, patient care, etc. Constantly determined to enlarge our range. We are, by the way, the only country at present to encourage access to triple therapies, as a bilateral measure.
Simultaneously, over time, our field of involvement has broadened: we are now working in 28 countries through 45 projects. This long-standing tradition allied to the experience of Aids in France - which has changed the way health systems, the sick and the role of voluntary organisations are seen - have meant that we were the first State, in 1997, to affirm that prevention cannot be separated from access to treatment.
L.F.: How has this global approach been perceived?
A.D.: We have been isolated. The international community took the view that while access to treatment was beyond the reach of developing countries everything should be staked on prevention. Yet without hope of care, this is pointless.
The first U-turn occurred with the French presidency of the European Union, from June to December 2000. We were then able to show, on the international stage, successful experiments in access to treatment, conducted thanks to the International Therapeutic Solidarity Fund (FSTI) set up in 1997 on the initiative of the French president, Jacques Chirac, and the present Minister of Health, Bernard Kouchner. Then, by working closely with the European Commission an innovative consensus was achieved, regarding not only Aids but also tuberculosis and malaria.
Three priorities have been established: to strengthen health systems, to improve access to medicines by every possible means (obtaining differentiated prices, the use of generic medicines and the transfer of technologies), and to support research (medicines, social aspects...). Gaining acceptance little by little, the European position was finally recognised in June 2001, at the extraordinary session of the General Assembly of the United Nations in New York.
L.F.: How much does French aid represent today?
A.D.: A quarter of the bilateral aid devoted to health co-operation programmes, which is 100 million francs (15.24 million euros) a year. In May, the Prime Minister, Lionel Jospin, also announced that of the 10 billion euros that the government will be allocating to the cancellation of the debt of the poorest countries, one billion will be devoted to the fight against Aids in the countries concerned, which is a considerable sum. In addition, France will contribute the sum of 150 million euros in three years to establishing the World Aids and health Fund, which will also finance actions against tuberculosis and malaria.
L.F.: What sort of programme is the International Therapeutic Solidarity Fund supporting?
A.D.: The FSTI is acting in five countries: South Africa, Benin, the Ivory Coast, Morocco and Senegal, and in two areas: prevention of mother-child transmission of HIV and the treatment of sufferers by triple therapy. It is in addition actively involved in devising the therapeutic solidarity hospital programme in progress. This French initiative, launched in June 2001, which has won over several European countries, aims to twin the hospitals of the North with those of the South. This will enable health professionals working in health centres in the South to benefit from the experience of teams in the North. Finally, already a UNAIDS operator, the FSTI may also become one for the World Fund.
L.F.: And on the ground, what kind of partnership has been established with the NGOs?
A.D.: Many people living with HIV are prepared to play a role in dealing with the epidemic. Therefore, everywhere that the FSTI runs access-to-care programmes, it actively involves local patients’ associations. Our spending also incorporates this dimension and credits are allocated directly to the associations. We are also working on a project for a Solidarity Fund which will prioritise support for the associations of the South. Lastly, we are trying to persuade the associations of the North to support their colleagues in the South. Thus Aides International has set up a South-South community network supported by the North.
Journalist
THE ANRS, FULL STEAM AHEAD ON VACCINE RESEARCH
Basic biological, clinical, epidemiological research, research into vaccines, public health, human and social sciences... There’s not a field in France that escapes the intervention of the French national Aids research agency (ANRS) on the subject of HIV.
Created in 1992, the ANRS has driven and financed a huge variety of research, from analysis of our behaviour, with a view to establishing appropriate prevention policies, to the examination of the problems of taking medication for long periods, from access to care and the screening of vulnerable groups to study of the infection itself.
In particular, the ANRS has conducted more than a hundred therapeutic trials on the primary infection, infection in the chronic phase, opportunistic infections, prevention of mother-child transmission - now down to less than 3% in France. It also supports programmes in developing countries where it is established (Africa and Asia).
The Agency’s present priorities relate to the care of patients not responding to treatment, the simplification of retroviral treatments and the prevention of side effects. Some 20 % of the 45.7 million euros (300 million francs) of its 2001 budget are allocated to vaccine research, which makes it one of the world’s leading actors in this field.
Coincidentally, a promising approach has been identified. It aims to obtain a cellular response, i.e. according to Jean-Gérard Guillet, head of the ANRS vaccine programme "to stimulate the production of killer cells, which will kill off infected cells in the event of HIV infection". Four trials are scheduled in 2001 and 2002 and will be conducted with the involvement of HIV negative volunteers. Lastly, immunotherapy, the object of which is to strengthen the immune system, is at the core of current research and is arousing new hope. Through vaccinotherapy in particular.
F. R.
On the internet:
• www.sante.gouv.fr/index.htm
• www.cooperation.gouv.fr/cooperation
• www.cfes.sante.fr
• www.eurohiv.org
• www.unaids.org
French fight against Aids inter-organisation site:
www.vih.org
It also has links to the following sites:
• www.actupp.org
• www.aides.org
• www.arcat-sida.org
• www.crips.asso.fr
• www.sidaction.org
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