Chicago Tribune - October 6, 2003
Laurie Goering, Tribune foreign correspondent

The 32-year-old mother of two has adopted a healthier diet, tried herbal remedies and attacked colds before they could turn into pneumonia. But her immune system has deteriorated. Now she has one last hope: free anti-retroviral AIDS drugs, part of a massive South African government-funded treatment program expected to be approved this month.

"A lot of us are waiting, and we're all praying together and hoping for it," Stevens said, while visiting a doctor at the jammed weekly AIDS treatment clinic at Soweto's huge Chris Hani Baragwanath Hospital. "We can't afford the drugs ourselves so this is our only hope."

While countries such as Uganda and Botswana pushed forward years ago with government-funded AIDS treatment programs, South Africa's leaders have long resisted providing costly anti-retrovirals. In a country where more than one in 10 people have the AIDS virus--5.3 million people, the largest number of any nation in the world--the government has called the costs of treatment too high, complained the drugs are insufficiently tested and insisted that South Africa does not have the infrastructure to launch a mammoth treatment program.

Government resistance to anti-retrovirals collapsed in August after outraged AIDS activists, pointing to declining costs for drugs, the epidemic's huge economic costs and the bitter death toll--more than 1,000 South Africans a day lost to the disease-- pressured the government to shift course.

Last week a national AIDS task force turned over a proposed countrywide treatment plan to South Africa's Cabinet, which is expected to hand the plan to the country's legislature this month for approval. Doctors and activists hope the first government-provided anti-retroviral drugs could begin finding their way to patients by November or, at the latest, January.

'Hanging on'

"We're hanging on by the skin of our teeth for this rollout," said Dr. Allison Russell, one of the physicians at the Soweto AIDS clinic, which provides anti-retrovirals only to those who can afford to pay or who are involved in clinical trials. That is about 10 percent of the clinic's more than 1,000 patients. But 75 percent would be eligible for the new government treatment program, doctors estimate.

Launching the world's largest AIDS anti-retroviral treatment program has risks. Because of the country's long reluctance to start such an effort, many doctors remain relatively untrained in prescribing and using AIDS drugs, and experts fear the country may not have the infrastructure or professional capacity to support a countrywide program, especially in remote rural areas.

"If our clinic's like this today, what will it be like then?" asked Dr. Alan Karstaedt, an anti-retroviral expert and head of the Soweto AIDS clinic, where more than 100 patients jam the tiny waiting room each day it's open. A steady stream of young doctors trickles through Karstaedt's busy examining room, asking for advice on drug interactions.

In a country where HIV-positive people face stigma, doctors fear that patients who enter drug treatment may by tempted to sell their medicine on the black market or share drugs with affected family members who refuse to come forward for tests and treatment.

Medical experts also worry that without proper supervision patients may be lax in sticking to sometimes complicated anti-retroviral drug regimens.

Studies show, however, that adherence to anti-retroviral drug programs in Botswana, Uganda, Senegal and parts of South Africa is nearly 90 percent, compared with a 60 to 70 percent adherence rate in much of the developed world.

In part, experts say, that's because Africans--surrounded by dying family members and friends, and worried about leaving their children orphans--are aware of what is at stake if they fail to follow the treatment regimen.

"I know if I want my life there's no other way," said Thembi Dubazana, 25, a patient at the Soweto clinic who started anti-retroviral treatment in June, using her $100-a-month government disability grant. Other patients, who are unemployed and use the grants to feed their children, must wait for free government drugs.

Cities likely first targets

South Africa's government likely will launch the first stage of its effort only in large urban hospitals such as Chris Hani Baragwanath, expected to be one of 22 initial treatment sites, and in regional rural hospitals where staff training is highest. Experimental treatment programs in very rural areas, such as KwaZulu-Natal province's Hlabisa district, have shown adherence rates of only about 50 percent, workers there say.

"I wouldn't want to say [the upcoming government program] will be highly successful everywhere," Karstaedt said. But in big urban centers "we've had excellent compliance and success in reducing viral load," he said.

The price of anti-retroviral drugs has fallen by half in the last five years, and as generic drugs begin to reach South Africa's market, doctors hope to reduce the annual cost of three-drug therapy--the most effective current treatment--to perhaps $42 a month, down from $70 to $120.

Still, with the worst of South Africa's AIDS epidemic still to hit, because of the long time between infection and symptoms, treatment will be costly. The Health and Treasury departments estimate that treating all the AIDS patients in the country will cost $2.4 billion to $3 billion a year by 2010.

Doctors point out, however, that the treatment program also will result in substantial savings and economic benefits as patients are able to return to work, avoiding hospitalization for complications such as pneumonia, and as demand for home care, disability grants and other expensive services for the terminally ill abates.

Many of South Africa's largest businesses have launched private treatment programs, based largely on a desire to cut costs, slow productivity losses and slow employee turnover.

Whether the programs will pay for themselves is "somewhat of a leap of faith," said Brian Brink, senior vice president for health of Anglo American, which runs some of South Africa's largest mines and one of the biggest private AIDS treatment programs.

What treatment will do, experts hope, is reduce the stigma surrounding AIDS. Only about 10 percent of HIV-positive Africans have been tested and know their status, doctors believe, in part because no treatment has been available. South Africa's new program should help change that, and stem the spread of the epidemic, they believe.

'They think AIDS is death'

"Definitely the stigma will go down with drugs," said Stevens, who still cringes when members of her church step out of the way when they see her coming. "I think people will be willing to be tested. Right now they think AIDS is death. If there's treatment that will change."

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