By Lawrence Goldyn

The New York Times 6 July 2000

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 pharmaceuticalbased 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 fastestgrowing 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 largescale TB programs with cheap, easytotake 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 subSaharan 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 motherstobe, 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 onethird 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 breastfeeding. So even if mothertochild 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 breastfeeding 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 bottlefeeding.

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.