AIDS conference : The real problem is getting the medicine out

By Colin Webb

Published: THURSDAY, JULY 15, 2004

LONDON: In recent years governments and international agencies have demonstrated laudable intent in the fight against HIV/AIDS. Billions have been pledged to combat a global pandemic affecting some 40 million people, most of them in the poorest countries on earth. But resources must be allocated effectively or so much goodwill is squandered. At present I can't say that they are.

AIDS 2004, the biennial International AIDS conference taking place in Bangkok this week, involves more than 10,000 delegates from across the world. With depressing predictability, the main focus is on the cost and supply of medicines. For years this has been the fixation of health activists and nongovernmental organizations. Thanks in part to their efforts, drugs companies now offer AIDS medicines at vastly discounted rates and even for free. Hats off to them.

But this obsession with the supply of medicines does not begin to tackle the realities of the health-care crisis that engulfs much of the underdeveloped world, where the basic health-care systems are simply not in place to provide effective treatment programs. We could spend millions on AIDS drugs and send them to Africa. Then what?

The European Coalition of Positive People has years of direct experience working in some of the world's poorest countries. Currently we have clinics in Malawi and Mozambique, countries where the majority live on less than a dollar a day, and HIV prevalence runs at more than 11 percent nationally and reaches 40 percent in some rural areas. ECPP, with tax-exempt status, could get drugs into the country cheaply and easily, circumventing the insane import duties and hidden costs that can add 40 percent to the price of medicines in Malawi. But I don't know what we would do with them once we got them there.

It is difficult for those not familiar with these countries to comprehend the scale of the task at hand. There are just 28 hospitals throughout Malawi. There is only one doctor for every 32,000 patients. Eighteen months ago, the country had just one pharmacist on the government payroll. One.

There is nobody to orchestrate a national HIV treatment program. There is no way to distribute medicines throughout the worst-hit rural areas, where there are no roads. There are few clinics to send them to anyway and inadequate storage and refrigeration facilities once they get there.

Under these conditions, the debate about access to medicines is purely academic. Complex antiretroviral therapies that require strict adherence are simply not an option today. Hospitals and health centers just do not have the staff to monitor whether patients are following treatment regimens; failing to do so greatly increases the risk of developing drug-resistant viral strains. How can you stop patients from sharing their medicines among their sick relatives — an act of charity toward the extended family that is natural to African culture?

Even in richedrugs cannot be delivered to those who need them. In Nigeria it was recently discovered that out-of-date drugs were being prescribed to thousands of patients. A leading drug manufacturer which had sent a huge shipment of free medicines to another prominent African country was recently asked to come back and change the labels: The drugs, which had never left the airport, had passed their sell-by date. Such incompetence, corruption and incapacity are rife throughout the continent.

Put simply, the problem is not supply of medicines. It is the lack of basic infrastructure to distribute those medicines. The current focus of those who want to simply throw drugs at countries that have no way of delivering them safely to patients is totally off the mark. Any effort to tackle the AIDS crisis that does not focus primarily on the basics is doomed to failure.

But influential groups continue to plug their silver bullet solution with alarming success.

Last year the World Health Organization announced its "3 by 5 initiative," an ambitious plan to scale up treatment to three million people by 2005. It is hopelessly unrealistic. Resources would be better spent in areas where tangible results can be achieved immediately and relatively cheaply.

We should be building and staffing health clinics, not just for HIV, but to treat the opportunistic infections that prey on AIDS sufferers and are the ultimate cause of death. We can develop community centers and orphanages that can be used to scale up education programs that focus on prevention. We should be digging boreholes and wells to provide clean and safe drinking water, a basic human need that many have no access to. We have to use our limited funds for something sustainable and transferable. The rest will follow.