BBC News - December 1, 2004
Orla Ryan, BBC News business reporter in Mozambique

Her husband left her and her neighbours shunned her when they realised she was HIV positive, leaving her struggling to support her six children.

Now she is full of fighting talk and enthusiasm, fuelled by the knowledge that if she had not found treatment, she would be dead.

Italian non-governmental organisation Sant Egidio in Maputo treats Ms Muhai with generic antiretroviral drugs (ARVs).

Sant Egidio was a pioneer of this treatment in Mozambique, where it launched a pilot project in 2001.

The trickle of money - and interest - in treatment with ARVs has become a flood.

The Mozambican government is now one of the recipients of US President George W Bush's $15bn Emergency Plan for Aids Relief (Pepfar).

Pepfar represents a healthy injection of cash into the fight against HIV/Aids. Just as importantly, it is the result of US recognition that action is urgently needed.

Spending rules

But Pepfar cash, however welcome, has attracted controversy.

It comes with restrictions that prevent the purchase of generics - cheaper, copies of brand name drugs.

Beneficiaries of Pepfar cash are only allowed to buy drugs approved by the US Food and Drug Administration (FDA). This effectively rules out the vastly cheaper generic treatments that Ms Muhai benefited from.

Avertino Barreto, a director in Mozambique's Ministry of Health and one of the coordinators of the HIV/Aids effort, welcomes the cash, but says the restrictions are unfair.

With less than $2 per head to spend on drugs, the Ministry's policy has always been to buy generics approved by the World Health Organisation (WHO).

The health ministry plans to treat 8,000 people with ARVs by the end of this year, using money from its own coffers and from other donors who do not have a problem with the generics. By the end of 2008, it hopes to treat 128,000 people.

Safe, cheap drugs?

Mozambique and other recipient countries have their hands tied by Pepfar's conditions.

Within two years, Pepfar money will account for about 20% of the country's HIV/Aids budget, Mr Barreto says.

Unless the generics have been approved by the US regulator, Mozambique will still not be able to use the Pepfar cash to buy ARVs.

Emotions run high when you talk of treatments for Aids, which is estimated to kill about 6,000 people each day in Africa.

Leading pharmaceutical companies argue that they need to charge higher prices to justify the billions of dollars they spend on research and development, costs which generic drug makers like India's Cipla and Ranbaxy do not have to bear.

There is also a view that generic drugs are unsafe.

Pepfar, which falls under the auspices of Randall Tobias, a former Eli Lilly chief executive, questions the safety of some generic treatments and the WHO has withdrawn its approval for some generic treatments.

Generic drug-maker Cipla, which views the Pepfar ruling as unfair, is currently applying for FDA approval.

Better use of the cash

Mr Barreto is among the first to say that money spent on drugs is just one part of the Pepfar story.

"We are using most of the money available for training," he says.

"Training doctors, training nurses, people for planning, people for management. ARVs is not a question only of drugs, you need to guarantee the system is functioning well," Mr Barreto says.

US diplomatic sources in Maputo agree.

"Drugs are an easy way to spend a lot of money," one official said. "The difficult part is to put the programme in place, training and using the healthcare system."

He points to the fact that there are only 650 doctors in Mozambique, many hospitals lack regular water and electricity supplies and there are only three labs where your CD4 count (a blood test which indicates whether you need to start taking ARVs) can be tested.

Mozambique is at a far earlier stage of the HIV epidemic than neighbouring countries. Just 14% of its population has the disease, compared with 40% in neighbouring Botswana.

This could justify spending more of the Pepfar money on prevention and improved healthcare than on buying ARVs, brand names or generics.

There is, however, no escaping the importance of treatment.

"Treatment is a component of prevention," a Maputo-based NGO worker says.

"When you propose testing and you don't have availability of treatment, you are giving someone a death sentence."

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