Cheap Drugs Are Only Part of Weapons Against AIDS

The Church of Scotland Hospital is located in an arid backwater of KwaZulu-Natal province, but it can provide results of an HIV blood test in minutes. It has two operating rooms, X-ray facilities and a basic laboratory.

Nine experienced doctors treat about 500 patients each day. At 13 clinics in the surrounding Msinga district, nurses who are in telephone or radio contact with the hospital attend to drop-in patients.

Two mobile clinics also offer free treatment. In the absence of addresses, they use global positioning systems to determine the location of AIDS patients who are at home. Volunteers follow up with patients to ensure that no one is simply left to die.

One thing that is lacking, here and in most of Africa, is a supply of inexpensive antiretroviral drugs that could help prolong the lives of people who have AIDS. But given the size of the problem in sub-Saharan Africa, and the dire shortages of good roads, communications, medical facilities and trained doctors, the question is how much of a difference the drugs could make.

“If this area was flooded with cheaper drugs, we would be very happy because we would definitely use them,” said Tony Moll, a senior doctor at the hospital. Fully 36% of the adults in KwaZulu-Natal province are infected. Moll estimated that, without proper treatment, 70,000 of Msinga district’s 350,000 people will die within 10 years.

Announcements by several major pharmaceutical companies that they will slash the prices of anti-AIDS drugs have given some hope to KwaZulu-Natal. On Wednesday, a massive AIDS prevention and treatment plan spearheaded by U.N. agencies was unveiled, and on Thursday, U.N. Secretary-General Kofi Annan persuaded six companies to cut their prices further.

Annan, who called AIDS “the greatest public health challenge of our times,” said he was also aiming for dramatic improvements in prevention, education and care.

KwaZulu-Natal has already put in place a structure to cope with the impact of the disease. Although it is far from perfect, doctors say it would help them distribute and monitor the use of antiretroviral medicines, were they to become widely available.

But the Msinga district is not typical--either of rural South Africa or the rest of the continent.

The annual health care budget of some African nations is less than $5 per person. Many hospitals lack equipment and medicine for even basic ailments. Doctors and nurses are in short supply. Poor roads and communications hamper access to medical facilities. And in much of Africa, the disease is treated as a badge of shame.

Intensive public awareness campaigns have helped Uganda cut its infection rate among adults from 14% to 8%. Senegal has kept it rate of adult infection close to 1%. But these countries are the exception.

Sub-Saharan Africa accounts for nearly 70% of the world’s 36 million HIV and AIDS cases and 90% of all deaths because of the disease. About 4.7 million South Africans, or one in nine of the 45 million citizens, are living with the virus.

The acquired immune deficiency syndrome has orphaned millions of children, crippled the labor force and slashed life expectancy. A recent U.S. study projected that life expectancy in Botswana could fall to as low as 29 years.

In general, access to antiretroviral drugs has proved to prolong lives. But in Africa, the impact would be minimal, many researchers say. The standard triple therapy costs about $10,000 to $15,000 a year. Even reduced to 20% of the cost, the drugs would remain unaffordable.

Zweli Mkhize, minister of health for KwaZulu-Natal province, said South Africa would need more than 10 billion rand, or $1.24 billion, for the next 10 years to build an infrastructure that could cope with an infusion of antiretroviral drugs.

“On its own, the question of drugs will certainly go a long way,” Mkhize said. “But that is not the complete picture.”

A South African law allows the import of cheap, generic medications, but leading pharmaceutical companies have been seeking to strike down the legislation, which they say would violate patent rights. The court challenge is set to resume April 18.

South African President Thabo Mbeki has come under fire for questioning the cause of AIDS and for stalling on authorizing the use of anti-AIDS drugs in public clinics. He says he is not opposed to the use of antiretroviral drugs as long as there is an infrastructure to properly administer them.

Mbeki and other African leaders have also been criticized for wasting money on armaments. South Africa is embroiled in controversy over the 43 billion rand--$5.3 billion--it committed to buying new European-built planes and submarines.

Rampant Poverty on the Continent

Tens of millions of ordinary Africans survive on less than a dollar a day. Many are subsistence farmers. In South Africa’s Eastern Cape province, almost half the 6.3 million people are unemployed.

“A lot of our patients cannot afford to pay the six rand (less than $1) to reach the hospital when they are desperately sick,” said Moll, the doctor. “You can forget about paying for antiretroviral drugs.”

Suffering from chronic chest and back pain and vaginal sores, AIDS patient Khangazile Ntombela depends on the $30 a month her husband sends from his job at a Johannesburg factory. Though she suspects that her spouse gave her the disease, she has kept her illness a secret for fear that he might abandon her.

“Sometimes husbands are naughty, and they are rude,” said Ntombela, 30, whose 3-year-old daughter died of diarrhea a month ago. “He might chase me away.”

Her monthly remittance is hardly enough to help keep her 5-year-old son alive, much less buy drugs that could extend her own life.

“The government would have to make these cheap drugs available to the poor, and they have to make them available for free because the poverty is so deep,” said Costa Gazi, director of the AIDS Babies Battling AIDS trust, or ABBA, which provides counseling and HIV testing to pregnant women.

Many in Countryside Lack Food, Water

Some anti-AIDS drugs are supposed to be taken on a full stomach, but finding food is a struggle for many country dwellers. Clean water is also needed to wash down some antiretroviral pills. But for most rural Africans, clean water is hard to come by.

A report by the World Health Organization earlier this year indicated that a community of 800,000 people in KwaZulu-Natal had no access to clean water. A recent outbreak of cholera infected more than 53,000 people and claimed more than 100 lives.

Roads would need to be built to remote villages. Laboratories would have to be constructed and refrigerators installed to analyze and store blood samples. An intricate communications system would have to be in place to ensure that stocks were kept up to date.

There is an overall shortage of medical personnel, and physicians qualified to prescribe antiretroviral drugs are few. Though the doctors at the Church of Scotland Hospital have laid the groundwork for the widespread distribution of anti-AIDS drugs, none has been trained to administer their use.

“The AIDS epidemic has underlined all the deficiencies of the public health system,” Gazi said. “If you don’t tackle the infrastructure, you cannot tackle AIDS.”

Difficult to Monitor Patient Compliance

And then there is the question of compliance. Medical officials acknowledge that it was hard enough ensuring that patients adhered to a course of antibiotics for illnesses like tuberculosis, much less getting them to stick to a strict and often complex regimen of sophisticated antiretroviral drugs.

“You need very good supervision and monitoring of your patients,” Mkhize said. “How do you say to somebody, ‘You should take this medication at a certain time,’ when they don’t even have a watch?”

Without proper supervision, patients might stop the treatment. Unreliable deliveries might stymie others. Researchers warn that such poor compliance could result in the emergence of a more resistant strain of HIV, the human immunodeficiency virus that causes AIDS.

Some argue that not enough is known yet about antiretroviral drugs to determine their benefits.

“We don’t really know the long-term impact of these drugs,” said Suzanne Leclerc-Madlala, a Durban-based medical anthropologist. “Maybe for orphans it will mean prolonged help. But maybe for those with the disease it will mean prolonged suffering.”

However, those who can afford the drugs argue that the medications break the equation between AIDS and death.

South African Constitutional Court Judge Edwin Cameron, who spends about $400 a month on a combination of anti-AIDS drugs, has appealed for them to be generally available at a more reasonable cost.

“There is a demand for antiretroviral drugs and a demand for greater care, and it is our responsibility in the medical profession to offer them,” said Daya Moodley, a researcher at the University of Natal in Durban.

Others argue that a steady supply of cheap anti-AIDS drugs will actually force African countries to improve infrastructure so that the medicines can be administered.

“Undoubtedly the infrastructure needs to be improved, but it’s not an excuse to delay bringing down prices,” said Nathan Geffen, a spokesman for the Treatment Action Campaign, a group that lobbies for better access to health care for the poor.

“With the cheaper drug prices, the pressure to improve the health care system would come. The cheaper drugs would be an incentive to get the infrastructure going,” Geffen said.

As a test, South Africa decided last year to provide milk powder and the antiretroviral drug nevirapine free to HIV-positive women in order to curb transmission of the virus to babies. But the program has been slow to take off because health officials want to learn more about the long-term implications of the drug first.

Meanwhile, activists say, thousands of mothers are dying and infecting their children.

Moll, whose hospital has been selected as a test site, said having access to nevirapine would be crucial.

“If I could take a mother from dying with a 3-year-old or 5-year-old child to dying with a 15-year-old, that would be magic,” Moll said. “It comes down to the impact on the individual and just being able to keep a breadwinner or caregiver in the home.”

Grandmothers Raise Offspring’s Young

Many grandmothers have taken over the role of raising young children. Elsie Mtetwa took charge of four of her grandchildren after her daughter and son-in-law died of AIDS-related illnesses more than seven years ago. Mtetwa, 52, earns only about $70 a month as a domestic worker but says she would have paid that--and more--for anti-AIDS drugs.

“I wanted so much for my daughter to get better,” she said.

Mtetwa’s grandchildren are lucky to have her. Parents of most of the 43 children at the Agape Child Care and Support Center in the remote village of Waterfall have died of AIDS-related diseases, or are too sick or poor to look after them. Kids share mattresses on the floor and play in two old shipping containers in the yard.

Two-year-old twins Londa and Londeka Zuke Mnpanza were brought to the center in January, emaciated, crying and covered in scabs. Their mother left them with an elderly male neighbor. Counselors suspect that she ran away to die.

“Commonly, mothers do not want to be seen dying in front of their children, or to see their children dying,” said Bonnie Phungula, a preschool teacher and volunteer counselor. “So it’s common to find children who have been dumped.”

Zodwa Mqadi, a community development worker who runs the child-care center, believes that antiretroviral drugs would give ailing parents a reason to live.

“It would reduce the stress of being sick and bring hope that maybe before they die some help will come, and maybe a cure,” Mqadi said. “As it is now, they just die.”

As the debate rages over cheap anti-AIDS drugs, many researchers and health officials say impoverished countries would benefit most from a flood of basic medicines to treat illnesses such as tuberculosis, hypertension and diabetes. Many patients die of those illnesses before their AIDS infection can develop full-blown symptoms.

In the end, even proponents of supplying cheap antiretroviral drugs say the solutions are much broader.

Mkhize, KwaZulu-Natal’s health minister, said the government and private sector must work together to educate people, ending a culture of denial about AIDS, as well as improving infrastructure and reducing poverty.

“The understanding of the cause of the spread of HIV/AIDS is more potent than the availability of drugs,” Mkhize said. “We should not say that the end of our problems would come with access to the drugs.”

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Africa’s AIDS Crisis

Sub-Saharan Africa accounts for nearly 70% of the world’s 36 million AIDS cases. African countries may be able to receive cheap anti-AIDS drugs, but poverty and lack of infrastructure will make it difficult to administer them properly.

Source: United Nations World Health Organization