Scarce money, few drugs, little hope

'We can't afford to spend money on people who are going to die'

A woman stands in front of her hut in northern Malawi with six of her nine grandchildren whose parents have died of AIDS. Africa has been overwhelmed by more than 10 million AIDS orphans

By John Christensen
CNN Interactive

(CNN) -- State of the art treatment has so increased the quality of AIDS patients' lives in the industrialized world that complacency has begun to set in. But that is not the case in Africa.

"When a baby gets bad," Dr. Iwan Bekker, head of pediatrics at a South African hospital told AIDS Weekly, "we won't admit it for a second time, but will tell the mother to take it home and let it die."

In the industrialized world, many patients are treated with a "cocktail" taken from a list of 15 or 20 anti-retroviral drugs. Each "cocktail" is tailored to meet the specific needs of the patient, and can cost as much as $15,000 a year.

Dr. Robert Janssen, director of the division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention in Atlanta, says the treatments have been so effective that the life expectancy for AIDS patients has increased dramatically.

"People are doing very, very well on treatment," Janssen says. "They're living longer and they're living better lives. And we haven't seen the end of the effectiveness of the drug. We haven't used them long enough."

But the success has created a paradox. After two years of dramatic reductions in deaths, the rates are leveling off and 40,000 new cases of HIV are still reported in the United States each year.

"We're seeing a complacency that's leading to unsafe behavior," Janssen says. "People think it's a treatable disease -- and there is more treatment -- but people are still dying of AIDS."

More than 17,000 people died of AIDS in the United States in 1998, the last year for which statistics are available. There are also reports of side-effects from the AIDS drugs, including problems with fat metabolism, heart disease, stroke, liver disease and osteoporosis and there is concern about increased infections among gay men and African Americans.

'Nothing to stop the epidemic'

In Africa, where there are 4 million new cases each year, the term "treatment" scarcely applies. With few exceptions, a positive test for HIV in Africa is a death sentence.

A 26-year-old woman, her arm covered with a skin infection, suffers from AIDS at the government hospital in Gulu, Uganda

"We don't even think about trying to halt the epidemic, but about how to manage it, how to slow it down," says Dr. Robert Shell of the Population Research Unit at Rhodes University in South Africa. "It's that big. There's really nothing to stop the epidemic here. It's just cutting through the population."

Sophisticated treatments are available only to the wealthy in Africa, and most Africans are desperately poor. In the United States, which has a population of about 274 million, about $10 billion in public and private money is spent each year on research, treatment and prevention of AIDS. The nations of Africa -- total population 543 million -- spend only $165 million.

AIDS victims often die from "opportunistic infections" such as pneumonia and tuberculosis, and cancers such as Kaposi's sarcoma. In developed countries there are drugs to treat such things and prolong the life of the AIDS patient -- but not in Africa.

"In some countries only 40 percent of the hospitals in some capital cities have access to basic drugs," says Dr. Badara Samb of UNAIDS in Geneva, Switzerland. UNAIDS coordinates the anti-AIDS efforts of five U.N. agencies, the World Health Organization and the World Bank. "Some hospitals, you won't even see tranquilizers, or very few."

"I've been in district hospitals that have aspirin and Tylenol," says Janssen, "but very little in the way of antibiotics."

'We feel very, very lonely'

The drug azidothymidine (AZT) has been effective in preventing the transmission of HIV from pregnant women to fetuses. (According to UNAIDS, 500,000 infants were born with HIV in 1999.) But such "short-course" treatments cost about $100 per patient, far more than most African countries can afford.

Promising tests have also been conducted with a drug known as Nevirapine, but at $4 a treatment even that is too expensive. Most countries spend no more than $10 a year per citizen on all health care.

In South Africa, which has a health infrastructure superior to most of its neighbors, there are 1,700 new HIV infections every day. Patients have overrun hospitals, and some must sleep on mats beneath beds that hold other patients.

An AIDS awareness notice erected by the health department on a busy street in Nazareth, Ethiopia, promotes the use of condoms

"The government will never be able to cope with it alone," says Manto Tshabalala-Msimang, South Africa's health minister.

Researchers are looking for an AIDS vaccine, but it is expected to be several years before one is found. Even then, national inoculation programs would have to be undertaken at tremendous expense.

Primitive health and transportation infrastructures would make getting the vaccine to far-flung populations a logistical and financial nightmare. And that assumes there are no complications, such as the war in Congo.

"I assure you, we feel very, very lonely and particularly vulnerable that we don't have the resources to set out a vaccine program that will work," says Shell in South Africa. "Every month that goes by is critical."

Meanwhile, the operative philosophy continues to be the one articulated by a medical researcher in Durban to AIDS Weekly: "We can't afford to spend money on people who are going to die."