Wall Street Journal - Monday, July 8, 2002
BARCELONA, Spain -- More than 14,000 doctors, activists and government officials -- including Secretary of Health and Human Services Tommy Thompson -- converged here for the opening of the largest AIDS conference ever, amid hopeful research findings about the efficacy of treating patients in poor countries. But such findings only dramatized the dearth of funds and political barriers to getting drugs to the millions who need them.
Mr. Thompson vigorously defended the U.S. contribution to the AIDS battle, saying the Bush administration is "absolutely committed" to the fight against the pandemic. Even though the U.S. has contributed more money than any nation, activists, who staged a large rally demanding drugs for poor countries, pointed out that as a percentage of its gross domestic product, the U.S.'s contribution is small.
For more information about the AIDS conference, see www.aids2002.com1 and www.unaids.org2
The Henry J. Kaiser Family Foundation this weekend released a comprehensive analysis of federal AIDS spending showing that such funding has increased every year since the epidemic surfaced. This year, total U.S. spending on AIDS is $14.7 billion, including prescription-drug outlays, Medicaid entitlement spending, scientific research and abstinence programs. Funding for the international fight against the pandemic is just slightly over $1 billion, according to the Kaiser analysis, including money for research and to agencies such as the Peace Corps. Yet the foundation said the administration is requesting only a 9% increase of less than $100 million when the need for poor countries has been estimated to be more than $9 billion.
Treatment for the world's poor is fundable and feasible, said Alan Berkman, a New York doctor and a founder of the activist group Health Gap. Mass AIDS deaths are therefore "no longer a tragedy but a preventable crime," he said.
Some experts have doubted that the complex AIDS drug regimens that have saved many lives in developed countries would work in impoverished settings, where many people lack basics such as clean water and decent housing. But Doctors without Borders, the Nobel Prize-winning group known by its French acronym MSF, reported promising results from 743 patients it has treated in seven poor communities in Africa, Asia, and Latin America. Most of these patients suffered from advanced HIV disease with severe immune-system deterioration.
Such patients frequently are too sick for the drugs to work. But among those who survived the first critical month on treatment, more than 92% were alive at six months, and most had gained weight and shown some immune-system restoration. Very few patients had stopped treatment because of side effects, MSF reported, and more than 90% adhered to the daily pill-taking regimen.
"Our results demonstrate the dramatic benefits" of AIDS drugs in poor settings, MSF said. "These results are all the more impressive as these patients began [AIDS therapy] in advanced stage of disease."
CASES WORLD-WIDE
Adults and children living with HIV/AIDS around the world as of 2001
Sub-Saharan Africa 28,500,000
But no hard-hit African country has been able to mass-distribute drugs to its people. Many experts are looking to Botswana to develop a model of getting treatment to all who need it. Botswana is one of the easiest places in which to accomplish this feat. The country has only 1.5 million people and a per-capita GDP among the highest in Africa. What's more, it is the recipient of a much-publicized $100 million treatment and prevention program funded by Merck & Co. and the Bill & Melinda Gates Foundation, with assistance from the Harvard AIDS Institute. Still, two years after that initiative was announced, only about 500 of the country's 330,000 HIV patients have taken antiretroviral drugs, the vast majority in the capital city of Gaborone. Almost 39% of the adult population is estimated to carry the virus, the highest prevalence rate in the world.
A major shortage of doctors and other medical personnel is the main obstacle, according to top Botswanan health administrators and Merck officials. The country has about 1,000 doctors but needs an additional 400, said Patson Mazonde, director of health services for Botswana. Most far poorer African countries don't have such massive financial backing, and so yet another effort, the Global Access Alliance comprising more than 20 public and private groups, has been launched to raise money and provide training to close the treatment gap.
This effort came in part out of frustration with the current United Nations system for getting drugs to poor countries, which activists criticized as needlessly complex. Mark Heywood with South Africa's Treatment Action Campaign said the U.N. should aggressively "introduce generic competition and stop talking about complicated tiered-pricing structures that take lots of time and don't work anyway."
The main vehicle for getting drugs to poor countries has been the Accelerating Access Initiative, a joint effort between various U.N. agencies and six large drug companies. That program requires individual countries to develop an AIDS action plan, and then the World Health Organization helps broker deals with drug makers on pricing and terms. Thirty-nine nations have developed AIDS plans under the program and 19 have negotiated deals with drug makers. In addition, countries in West Africa and the Caribbean have formed regional negotiating blocs. Indeed, over the weekend Caribbean nations reached a deal for steep discounts and expect to sign the pact in Barcelona this week.
Even administrators of Accelerating Access Initiative acknowledged that elements of the program are "obsolete" but noted that the World Health Organization is encouraging countries to purchase the best and cheapest drugs by distributing a new list of approved generic AIDS medicines.
Merck says the problem is the lack of political will in poor countries: Only 49 of the 112 eligible nations have ordered its reduced-price drugs. The situation in South Africa has been considered one of the most tragic and frustrating to activists. Until recently, the government opposed the use of antiretroviral drugs in public clinics, driven by the doubts of President Thabo Mbeki as to whether HIV causes AIDS and whether AIDS drugs are too toxic. The government has even resisted the use of antiretroviral drugs to prevent the transmission of HIV from a pregnant mother to her baby, an inexpensive intervention that has proved safe and effective in Africa. Activists had taken the government to court to force a change to that policy, and on Friday, South Africa's supreme court ordered the government to implement "without delay" a program to use the drugs to prevent mother-to-child transmission.
Separately, at his news conference, Secretary Thompson said that the U.S. would continue its policy of not funding what most AIDS experts consider one of the most effective prevention tools: needle exchange programs to slow the spread of HIV among injection drug users. Intravenous drug use is driving the epidemics in the former Soviet bloc, western China and Iran, as well as in the African-American population. Several federally funded reviews of the practice have recommended that it be implemented.
Asked if the government would fund needle exchange, Mr. Thompson didn't answer until the government's top AIDS scientist, Anthony Fauci, leaned over and whispered to him. Mr. Thompson noted that President Clinton had decided not to allow federal money to fund needle exchange and said the policy "would not change." Later, Dr. Fauci said that he told the secretary "Clinton said no and we're saying no."
Write to Mark Schoofs at mark.schoofs@wsj.com and Rachel Zimmerman at rachel.zimmerman@wsj.com
South and South-East Asia 5, 600,000
Latin America 1,500,000
Eastern Europe & Central Asia 1,000,000
East Asia and Pacific 1,000,000
North America 950,000
Caribbean 420,000
Western Europe 550,000
North Africa and Middle East 500,000
Australia and New Zealand 15,000
Source: UNAIDS