TCS Daily

Realism on African AIDS

By Roger Bate - February 5, 2003 12:00 AM

President Bush wants to help end the AIDS crisis in Africa. It's a laudable aim but will throwing $15bn of taxpayer funding at the problem ensure its demise? The answer is a resounding no.

The reality is that African countries are too backward at least for the foreseeable future to combat a disease likes AIDS even with massive help. That doesn't mean the effort is pointless. Far from it. But given its target, failure is likely, and could be embarrassing for the President in the 2004 campaign.

To be fair, the President doesn't think he can end the crisis alone, and part of the aim of the donation is to encourage Europe and Japan to do more. His funding is to prevent seven million new cases from occurring and to treat two million AIDS victims in the next few years. The former is unlikely but possible, the latter impossible.

President Bush cites the example of Uganda where HIV rates have fallen by 50% over the past decade. This has mainly been due to political will from Ugandan President Museveni in providing widespread public education (backed by aid), condoms and promoting abstinence, which reduced the number of new AIDS cases. The fact that there are 50% fewer cases is a considerable success, but at least partially this is because so many people have died and are therefore no longer in the current statistics. Nevertheless, if other countries provide the same kind of local political leadership, and the aid community helps with condoms and educational materials, then reducing African cases by 7 million over the next five years (of the expected 12 million) is possible.

Treating two million, on the other hand, is a whole new ball game. Treatment requires health infrastructure, hospitals with electricity and potable water, nurses, doctors, refrigerators, expensive diagnostic equipment in laboratories, as well as drugs. Few African countries possess all of these attributes outside of major cities. And in some countries even the capitals don't have ample supplies of all the complex diagnostic equipment.

All previous attempts to treat large numbers of people have failed. Nigeria announced in 2000 that with the necessary aid (it subsequently received over $100m from aid agencies) that it would treat 15,000 people by end of 2001. President Olusegun Obasanjo of Nigeria announced that he had completed a deal with Indian drug company Cipla to buy cut-price anti-AIDS drugs (this is the same supplier Bush implied, and his staff confirmed, would supply AIDS drugs for his programs). The drugs were bought and the western liberal media claimed it a great success.

But today, even with President Obasanjo's assurance of success, at most 1,000 urban people have been treated. Worse still, the stockpile of drugs will expire in less than three months so the whole exercise is likely to be considered a total failure. At least if Nigeria had worked with a western drug company like Merck, the drugs would have been replaced when failure occurred, but Cipla has made no such assurance. These are the dangers for President Bush for getting into bed with drug suppliers who supply on cost alone and cannot afford to replace old medicines.

Furthermore, generics companies have a lower stake than the research-based industry in restricting the build up of viral resistance to their drugs. Resistant rates in Uganda have been as high as 75%, making drugs useless. Modern triple drug therapy reduces the chances of such significant resistance developing but its still more likely in an African setting where mistakes are more likely to be made on dosing, timing and other factors of a drug regime.

While resistance and other factors make research drug companies wary of widespread drug use in Africa, the main concern is that there simply is not the medical infrastructure to deliver drugs to those that need them. And as Stephen Lewis, Special Envoy on AIDS in Africa of UN Secretary General Kofi Annan, said at the time the Nigerian program was launched it will be 'at least initially larger than anywhere else in the continent'. Yet it managed to treat 6% of its target, a year late, even with significant aid and drugs

President Bush aims to treat 2,000 times as many people as were treatable in Nigeria, which seems highly implausible. It would probably require the level of effort involved to fight a war with Iraq; at least a billion dollars a day and hundreds of thousands of experts in fields as diverse as civil engineering, immunology, medical education and street theatre. It's also arguably true that the money would be better spent on combating curable diseases like malaria and dysentery, but that is a topic for another article.

If there is hope, it is because the experts have learned from the Nigerian disaster. For example, Nigerian treatment failed partly because of the stigma attached to the disease. The treatment scheme required patients to go public about their HIV status and made attendance at designated hospitals compulsory. A confidential treatment program would have achieved better results - and with an education program to compliment it, which may help to lower stigma, treatment levels could jump.

But don't hold your breath. It is likely that by the time the Presidential election campaign heats up, next summer, very few additional people will have been treated. The Bush plan will be seen as a failure.

Dr Roger Bate is a Director of Africa Fighting Malaria a health advocacy group in South Africa

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