Chicago Tribune - April 8, 2005

No, you wouldn't expect HIV/AIDS to be the inspiration for a beauty pageant.

What's to celebrate about being infected with a deadly disease? Life expectancy in Botswana has dropped to 39 years from about 70 years, largely because of the epidemic. In this country of 1.6 million people, 40 percent of the adults are HIV-infected, among the highest infection rates in a world where AIDS continues to rage--particularly in its most impoverished regions.

Botswana officials say the stigma associated with being HIV-positive keeps many people from getting tested or seeking treatment. The pageant tries to cut through such fears. And Botswana might be on to something. For all its problems, Botswana has one of the most extensive and successful AIDS treatment programs in Africa. This is, in short, a place that offers lessons--some encouraging, some sobering--for the Third World.

In 2002, Botswana launched the first program in Africa to offer free universal treatment with anti-retroviral drugs, ARVs, until then a luxury reserved for developed countries. As of December, approximately 38,000 Batswana, or 40 percent of those who needed it, were receiving ARV therapy. The treatment will keep scores of HIV-infected people alive and reduce viral loads so those afflicted are far less contagious.

The question is whether a nation such as Botswana will be able to bear the burden of its own success.

Since ARVs became widely available in the U.S. during the early 1990s, the annual death rate from AIDS here has dropped by two-thirds, to 17,000 in 2002 from 51,000 in 1995, according to the Kaiser Family Foundation. New annual infections peaked in 1993 at approximately 80,000, before plummeting.

However, the yearly number of new infections in the U.S. remains at 40,000. One factor appears to be that reduced fear of AIDS as a certain death warrant has prompted more of the high-risk sexual behaviors that contributed to the epidemic in the first place. A similar trend may echo in Botswana and other poor lands.

As more people survive, the number of those requiring expensive, lifetime treatment rises exponentially. The number of people in the U.S. living with AIDS doubled to 405,926 between 1994 and 2003. In 2000, the federal Centers for Disease Control and Prevention estimated nearly 1 million Americans were HIV-positive or had full-blown AIDS.

To maintain survivors on costly medication, Botswana and other African nations beginning to offer ARVs will require billions of dollars in aid for the foreseeable future. Drugmaker Merck & Co. and the Bill and Melinda Gates Foundation have pledged $50 million each to Botswana. It has received $9 million, too, from the multinational Global Fund to Fight AIDS, Malaria and Tuberculosis.

In 2003, President Bush committed $15 billion over five years for a worldwide campaign to fight AIDS, mostly in African countries. That has made the U.S. by far the largest contributor to the international fight against AIDS and also to the multinational Global Fund. For 2006, the administration has requested a total of $3.2 billion for the entire AIDS effort. However, total pledges by all countries to the Global Fund are down to $673 million for 2006, from a high of $1.5 billion in 2004. The U.S., which pegged its contribution in part to what other nations would ante up, also has reduced its 2006 contribution to the fund. The general drying up of contributions to the Global Fund threatens its effectiveness and even survival.

At the same time, Bush's own plan to fight AIDS provided $35 million to Botswana in 2005 for a variety of purposes--prevention, testing and ARV therapies, among others--and the U.S. will match that amount for 2006.

Treatment for infected patients is an expensive proposition in the U.S. But in Botswana? Purchasing enough ARVs to help those in need there--and survivors in other African nations that are beginning to offer ARV therapies--will require billions of dollars for the foreseeable future.

Improved medical treatment of HIV/AIDS is a critical breakthrough. But prevention of the disease remains the key to success--in Africa, in the U.S. and everywhere else.

Botswana presents hope that the despair AIDS has brought to Africa can be relieved. And it presents stark signs of the challenges ahead.

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