A revolution in AIDS treatment for poor countries.

A revolution in AIDS treatment for poor countries.

A revolution in AIDS treatment for poor countries.

Health and medicine explained.
Oct. 16 2003 4:21 PM

Revolutionary War

How AIDS treatment for poor countries became possible.

Last May, at the AIDS clinic in Port-au-Prince, Haiti, I interviewed a healthy young mother who had been close to death only a few months before. I had traveled to the clinic because President Bush had just listed it as one of the recipients of his three-year, $15 billion unilateral program to combat AIDS in Africa and the Caribbean. As a reporter, I'd been there many times over the past two decades to cover this plague. Before, it was always the same despairing story of AIDS in a very poor country—patients getting only palliative care, their children destined to join the world's 14 million AIDS orphans. Yet in the past few months, with funds from the U.S. government and other donors, doctors at this clinic have begun dispensing anti-retroviral drugs (also known as triple combination drug therapy) that can dramatically prolong the lives of people with AIDS.

And it is not just in Haiti. Clinics in Uganda, Vietnam, Mozambique, and Brazil, as well as dozens of other countries, are offering people too poor to afford a few aspirin a lifetime course of amazingly effective AIDS drugs that, in the United States, cost upward of $10,000 year. To be sure, the effort is in its infancy. Those getting the drugs in poor countries worldwide number in the thousands while UNAIDS, the U.N. program on HIV/AIDS, estimates that 40 million in the world are now HIV-infected, with 6 million sick enough to need the therapy immediately. Still, this is nothing less than one of the greatest health-care revolutions ever attempted.

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Only three years ago, almost every international health expert agreed that drug treatment for poor countries was simply impossible. For one, the cost was astronomical and would drain funds that could be used to fight other deadly diseases in these areas, such as malaria and tuberculosis. For another, anti-retroviral drugs control the virus but don't cure it, so providing them represents a long-term commitment. Doctors worried about the logistics of administering complex medications in places with ramshackle roads, inadequate hygiene, and no running water. What if people missed doses, allowing drug-resistant forms of the virus to emerge? Experts also worried that if people believed there was an effective treatment for AIDS, then prevention efforts would fail. Suddenly, these objections have been cast aside.

How did the change occur? Those who have fought for the idea of effective global treatment for AIDS in the face of intense cynicism are a small but diverse lot: bureaucrats and politicians from rich countries, poor countries, and the United Nations; academics; and several nongovernmental groups, most notably Ralph Nader's Consumer Project on Technology and Médicins Sans Frontières. And as with any change in policy, activists played the critical role. Perhaps the most influential and effective group of activists is ACT UP, a loose coalition of organizations around the world, started in 1987 by novelist and playwright Larry Kramer. ACT UP has effectively used intensive but nonviolent harassment—of politicians, drug company executives, or scientists—combined with reasoned, informed discussions to bring about its desired results.

In the mid-1990s, when researchers discovered the dramatic effects of the triple combination therapy, some ACT UP members began to challenge the conventional wisdom that treatment could not be provided to poor nations.

ACT UP's heckling of Al Gore during his 2000 presidential campaign proved to be a critical turning point for the international AIDS effort. The Clinton administration, with Gore playing a major role, had actively enforced draconian trade agreements that severely punished poor countries for either manufacturing or importing cheap generic versions of the AIDS drugs. Clinton and Gore, it turned out, were on the wrong side of an issue that mattered to key constituencies. In a matter of months, the Clinton administration reversed its position on the trade sanctions.

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But the drug prices did not come down immediately. To this day, activists are waging convoluted battles with drug manufacturers on a country-by-country basis. It is hardly surprising that the companies fear the idea of selling the drugs for a tiny fraction of the price they can charge in wealthier countries. In fact, it was only the availability of generic knockoffs—especially those from India—that brought the prices down significantly. In February 2001, an Indian company named Cipra announced it would sell the drugs to Médicins Sans Frontières for $350 a year. "A dollar a day," as it became known, was a figure politicians could grasp.

As affordable drugs became a real possibility, a movement that had been building in Europe and the United States to increase AIDS assistance to developing countries quickly gained momentum. A surprisingly broad coalition developed in Congress in favor of a massive international effort. (The support of conservatives was won with the understanding that the money would not go to the United Nations.) In May 2001, Kofi Annan called for a new AIDS program outside the auspices of the United Nations, funded by wealthy nations, with an eventual goal of spending $8 billion a year. A month later, the G-7 heads of state established what would become the Global Fund To Fight AIDS, Tuberculosis, and Malaria. President Bush pledged $1 billion a year from the United States, as long as the sum of contributions from other wealthy nations were double that.

Bush has embraced the AIDS issue with far more fervor than even many in his administration had predicted, with promises of more money than Clinton ever offered. (AIDS funding plays well to many constituencies if the recipients are not drug users or homosexuals.) Bush has also kept the relaxed agreements on drug patents for poor countries enacted by Clinton in the face of the activist pressure on Gore. In this year's State of the Union address, he called for the five-year, $15 billion unilateral program to be distributed to specific programs in several designated African and Caribbean nations. (Not surprisingly, Bush was not eager to give all the U.S. funds to an international effort, even if it does exist outside of the United Nations.)

In the short time that the political will developed to deliver the AIDS drugs to poor countries, evidence accumulated that doing so was technically feasible. The biggest success story to date is Brazil. With the strong political leadership that has been lacking in other countries facing an AIDS epidemic, Brazil made a commitment in 1997 to treat every citizen with HIV/AIDS who needed it. The treatment efforts not only worked, they enhanced prevention campaigns. When people realized effective treatment was available, they started showing up for testing; once people know they are infected, they are less likely to pass on the virus. In 1994, the World Bank estimated that by 2000, Brazil would have 1.2 million people infected with HIV. Today, the number infected in Brazil remains half that. Reports from much poorer countries such as Uganda and Mozambique show that (at least in the initial, well-monitored pilot programs) patients adhere to their regimes at even higher rates than those in the United States.

Yet the numbers of patients receiving treatment worldwide do not even begin to put a dent in the astounding figure of 9,000 people dying of AIDS every day. How many will receive treatment before they succumb depends, of course, on how much money rich countries are truly willing to earmark. Bush's promised funds for both the Global Fund and his unilateral effort add up to $4 billion for next year. But his latest budget request asked for only $2 billion, and Congress may further reduce that amount. The United States hardly stands alone in reneging on pledges for AIDS funding. To date, the United States has contributed $623 million to the Global Fund while European nations have given $695 million, far less than the $8 billion a year total originally envisaged. The Global Fund has committed a total of $1.5 billion to support 150 programs in 93 countries, but its officials now worry that it could go under. And money is only the beginning of the problems. Many of the most afflicted countries face difficult bureaucratic challenges along the way, including building the necessary infrastructure to deliver the drugs, finding skilled health workers, and protecting the programs from government and internal corruption.

Despite all this, there is no denying a revolution has occurred during the past three years. In 1996, Eric Sawyer from ACT UP screamed at an international AIDS meeting, "It's time we start talking about global access to health care," and few listened. In a speech last May, President Bush said his AIDS plan shows how "a moral nation" can use its wealth and ability to help "solve unimaginable problems, to help the people who are needlessly dying." It doesn't seem impossible to hope that someday we might not idly watch millions die for lack of drugs that we have the power to distribute.