AFRICA CAN'T JUST TAKE A PILL FOR AIDS
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
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
Lawrence Goldyn, a doctor who formerly taught
political science at Parsons School of Design, treats H.I.V. positive patients.