Mail & Guardian (Johannesburg) - July 7 2000
Belinda Beresford and Khadija Magardie

Aids is a socio-economic disease - if you're rich you're more likely to avoid full-blown Aids for longer than if you're poor, because you can afford the medical care.

International aid agency Médécins sans Frontières says the South African government currently pays $4,15 (R29) for a daily dose of fluconazole, an anti-fungal medication needed to treat opportunistic infections in Aids patients. In Thailand a generic of the drug is sold for $0,29. There are hopes that the international gathering of experts will unveil movements on the much-trumpeted agreement between pharmaceutical companies and United Nations agencies to cut the price of Aids drugs.

Aids activists have been concerned that any deal with drugs companies would require participating countries to agree to conditions - such as promising not to allow the import or production of generic drugs.

According to UNAids research, where generic competition was allowed, drug prices fell by an average of 80%. Where there was no such competition, prices dropped by less than 20%. One American consumer organisation says Asian producers of generic Aids drugs could offer a triple-drug regime for about $0,63 a day, if sufficient economies of scale were achieved.

Aids is also a social issue. Dr Anthony Fauci, who is the director of the United States National Institute of Allergy and Infectious Diseases, says it's the social, economic and other health issues which lie at the heart of HIV's rampage across sub-Saharan Africa. Fauci, a leading international Aids expert, says disrupted family lives, truck routes across the continent, wars and untreated sexually transmitted diseases all assist the virus along its way.

But there are suggestions that genetics may play a role. Researchers have found that a small number of whites (about 1%) have a genetic mutation that makes it extremely unlikely that they will catch the virus. Other research has suggested that there are other genetic mutations that make it likely that a proportion of African-Americans are more predisposed than the population as a whole to catch the virus. Genetic differences between racial groups are known to play a factor in how people succumb and respond to diseases and treatments, say doctors, although such differences are likely to be less significant than external factors such as poverty.

Whatever the reasons behind the epidemic, responding to it is an ethical minefield, where a step in any direction appears to raise more issues and problems.

Anti-retroviral cocktails of drugs have led to a large decline in the number of Aids deaths in the US. But the drugs are expensive and using them brings problems.

HIV is highly adaptable and can become resistant to an individual drug in just a couple of days. If an individual doesn't follow the treatment plan, the drugs taken become useless as the virus becomes resistant. That's a problem for the individual concerned since there is a limited range of drugs available. But it's potentially a minefield for the population as a whole. If an HIV-infected person with a resistant form of the virus passes the infection on, eventually that particular drug will become useless for everyone.

One leading South African epidemiologist says even if cost were not an issue, one needs the infrastructure to hand them out. "You need some control of the supply because if you put these drugs out like Smarties, they will end up with them being abused and lose a wonderful drug." But Aids experts and the South African government have repeatedly pointed out that the price of medication is only one of the costs involved in controlling the HIV pandemic. Additional costs include testing people to ensure they're on the correct medication, counselling them, and the additional strain on the health system as a whole. All of which means that the way that the drugs are used can dramatically affect cost.

For example, giving Neviropine to women in the last stages of pregnancy appears to dramatically cut the chances of the child being infected. The medication required costs just under R30. But according to one World Health Organisation expert the true price is much higher once you factor in all the infrastructure costs behind giving that pill - about R10 000 a life.

Meanwhile, the international scientific community is bracing itself for President Thabo Mbeki's opening address at the conference to hear whether he will backtrack on his controversial quest to probe basic Aids science.

The weeks preceding the conference have been dogged by controversy, culminating in the signing by 5 000 doctors of the "Durban declaration" - a document that reaffirmed the accepted scientific belief that HIV indeed cause Aids.

This week Mbeki's 30-strong panel appointed to settle the matter resolved to re-examine the reliability and accuracy of the standard Aids test used to determine HIV positivity. Influential scientists like Dr Helene Gayle of the Atlanta-based Center for Disease Control and the Medical Research Council's Professor Malegapuru Makgoba are some of the prominent names who will be involved in "testing the test".

According to a dissident advisory panel member, Dr Harvey Bialy, the decision to re-evaluate the Elisa Test is a sign of Mbeki's integrity and refusal to be swayed by external pressures. Bialy is an internationally renowned molecular biologist and was one of the first PhD graduates from the first molecular biology department in the world, at the University of California.

He was highly critical of the fact that the lure of financial incentives and lucrative research funding has come to dominate Aids research, and was diluting the purity of science as a result.
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