TCS Daily

Fighting AIDS in Africa: What Works

By Richard Tren - May 14, 2003 12:00 AM

It has been several months since President Bush announced his decision to offer $15 billion to African and Caribbean countries to fight AIDS, yet it isn't quite clear how best to spend the money. Recent experience in some African countries could provide some important clues.

In 2001 Nigeria boldly announced that it would be importing cheap generic drugs from Indian manufacturers in order to treat around 15,000 adults and children with anti-retrovirals. The outcome was less than spectacular as reports emerge that fewer than 1000 are actually receiving treatment and that the drugs that were imported are nearing expiration.

One of the major problems with Nigeria was that although the treatment was offered very cheaply, the important clinical tests that went with it were expensive and out of reach of most Nigerians. In addition, the health infrastructure and expertise to administer the therapies was and continues to be sorely lacking, compromising the ability to deliver any kind of treatment.

Around a year ago, Zimbabwe declared an AIDS emergency and announced that it would allow the importation of generic drugs to treat those in need. The move was criticised by local activists who instead wanted the government to spend funds improving health infrastructure and training doctors and nurses. It is a pity that their calls were not heeded as to date no generics have been imported and no one has benefited.

South Africa has the most advanced economy and health infrastructure in Africa, and yet the situation with regard to AIDS treatment becomes ever more outrageous and unacceptable. Despite the noble efforts of activist groups, the government has prevaricated and stalled widespread and comprehensive HIV/AIDS treatment. It has delayed signing a donation agreement of $41m from the Global Fund claiming it needs to dot i's and cross t's. To delay in the face of such desperate need for treatment because of some bureaucratic requirement is not only malicious but verges on the criminal.

Botswana however seems to be getting things right. With strong political leadership from President Mogae as the country grapples with one of the highest HIV infection rates in the world, the country has partnered with the Gates Foundation and pharmaceutical giant Merck. The program known as the African Comprehensive HIV/AIDS Partnerships is building the basic but very necessary infrastructure to deliver comprehensive HIV care and ensure that it is done properly. More and more people are now receiving treatment and have been given a brighter and longer future as a result.

Both Gates and Merck have provided $50 million over the next five years. That's essential if the country wants to achieve anything. But the success so far in Botswana has been in recognizing the need to build the basic infrastructure first and to provide the political will to achieve some ambitious goals. These factors are all missing in Nigeria, Zimbabwe and South Africa.

Of course the history of donor transfers and aid to Africa is pretty appalling. In the past government to government aid has only kept some of the most despicable governments in power, has distorted markets and ensured that most Africans are poorer now than ever. If aid is to be spent, it has to be done in a way that is transparent, accountable and based upon good scientific and medical evidence.

The example of aid for malaria control does not augur well for HIV/AIDS. Shortly after the Second World War, the U.S. donor agency, USAID funded a global malaria eradication program, based mostly on the use of DDT. Eradication failed, but now USAID and most other donors refuse to fund any kind of malaria control using insecticides and most certainly would never fund the use of DDT. This despite the growing evidence that DDT and insecticides form an essential part of any successful malaria control program. The donors aren't doing Africa any favours when they only fund the more politically acceptable bed nets.

President Bush should be congratulated for wanting to help Africa deal with its AIDS problem, but most of the responsibility for implementing programs still lies with the various African governments. It is increasingly clear which countries are making things work and which are not. Let's hope that the Bush AIDS program is able to change the political will within Africa to tackle the problem, because without it, no amount of money will make any real difference or save any lives.

The author is Director of the health advocacy group Africa Fighting Malaria and a TCS columnist.

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