July 6, 2000

 

Africa Can't Just Take a Pill for AIDS

 

New York Times-July 6, 2000

 

By LAWRENCE GOLDYN

 

           SAN FRANCISCO -- President Thabo Mbeki of South Africa has

           so exasperated AIDS researchers that some have decided not to

          attend the international AIDS conference next week in his country. First

          he said AZT, which has safely helped prolong the lives of hundreds of

          thousands of people with H.I.V., might be too toxic for his people. Then

          he announced that he was willing to entertain the ridiculous views of the

          marginalized scientists who say H.I.V. does not cause AIDS.

 

          But when Mr. Mbeki spoke to an audience in San Francisco a few

          months ago, his iconoclasm began to make sense. He focused on a stark

          reality: the pharmaceutical-based model of H.I.V. care in the West is not

          applicable to South Africa. He may be arriving at this conclusion by a

          route involving some indefensible detours, but the conclusion itself is

          sound.

 

          The stakes are high. South Africa has one of the fastest-growing H.I.V.

          epidemics in the world, though with 20 percent of the adult population

          infected, it is in better shape than many of its neighbors in southern

          Africa, where 25 percent to 35 percent of adults have H.I.V. Most of the

          infected South Africans will die of AIDS, leaving behind hundreds of

          thousands of orphans with fewer resources and adult caretakers than if

          AIDS had been kept at bay. The economy is likely to weaken as people

          in their working years fall ill. The world held its breath as South Africa

          moved essentially bloodlessly from apartheid to a stable democratic

          government. Will H.I.V. unravel its stability?

 

          Cost is the obvious barrier to drug therapy. A cocktail of drugs for an

          H.I.V. patient costs between $10,000 and $15,000 a year --

          unaffordable at a tenth of the price for the South African government,

          which spends about $40 a year per person on health care. But Mr.

          Mbeki stressed something else: the lack of social, economic and medical

          structures to support drug treatment. Even in the West, where we have

          an array of social agencies to help, patients do not always comply with

          complicated regimens of H.I.V. treatment. If cheaper drugs arrived in

          South Africa by the shipload, how would one get people to take them?

 

          The history of another disease, tuberculosis, is sadly instructive. For

          years some southern African nations have had large-scale TB programs

          with cheap, easy-to-take drugs, but have not made a dent in infection

          rates. Meanwhile, on black markets, TB drugs have different value

          depending on whether they are "wet" or "dry." A wet pill is one that a

          patient puts under his or her tongue in the presence of a health care

          worker and then spits out later to sell. If South Africans had easy access

          to H.I.V. drugs, imagine their black market value in the rest of

          sub-Saharan Africa, where there are virtually no medications.

 

          A more immediately compelling issue is transmission of H.I.V. from

          mother to child.

 

          In the United States, AZT for mothers-to-be, combined with Caesarean

          section and other medical care, has practically eliminated transmission

          during birth, and when Mr. Mbeki dismissed AZT, he angered many

          physicians. But in a way his stance is perfectly rational.

 

          With no medical intervention, about one-third of children born to an

          infected mother will contract H.I.V.; AZT treatment alone could cut this

          rate in half. But the United Nations estimates that 15 percent of H.I.V.

          positive mothers infect their children through breast-feeding. So even if

          mother-to-child infection were lowered at birth to 15 percent, six months

          later it would still be around 30 percent.

 

          One might legitimately ask if an AZT program is worth the effort and cost

          if you still end up with a 30 percent infection rate among infants.

 

          There is no alternative to breast-feeding for most women in South Africa.

          There is little infant formula, and even if there were more, many rural

          women would not have clean water to mix it with. Moreover, H.I.V.

          carries such a social stigma that infected women have been driven from

          their homes and villages. Few would want to signal infection by

          bottle-feeding.

 

          What Africa most needs is an H.I.V. vaccine. Although there is an

          international research effort, pharmaceutical companies, motivated by

          profit, have not put their formidable resources into a vaccine, since the

          nations that need it would not be able to pay much for it. Controlling

          H.I.V. in South Africa now would require an international effort on the

          scale of the Marshall Plan: creating incentives to produce and distribute

          medicines and providing clean water, sanitation, clinics, health education,

          refuge for women and care for children. This is not on the horizon.

 

          That leaves South Africa little choice but to aim for less and hope for an

          affordable vaccine. The best policy would probably be to provide

          inexpensive antibiotics to fight the principal opportunistic infections of

          AIDS and the sexually transmitted diseases that increase H.I.V. infection

          rates, and to finance preventive education and efforts to destigmatize

          H.I.V. infection. As Mr. Mbeki says, the Western model of fighting

          AIDS is of little use to Africa now.

 

          Lawrence Goldyn, a doctor who formerly taught political science at

          Parsons School of Design, treats H.I.V.-positive patients.