Newsday - December 28, 2003
Laurie Garrett, Staff Writer

Nothing short of a revolution has happened, says Gomez, who runs AIDS treatment for the island nation. A year ago dying patients lay in the hospital, staring hopelessly. Today patients flock to the outpatient clinic, where anti-HIV medications are dispensed free of charge. The HIV nursery is empty, as the numbers of children born infected has plummeted. And Gomez says credit for the island's newfound optimism belongs to the William J. Clinton Foundation.

A year ago only handfuls of HIV patients in the Bahamas could get the medicines that have proven to be lifesavers in the United States and other wealthy countries. At the close of 2003, the United Nations AIDS Programme estimates that fewer than 800,000 of the 40 million people living with HIV infection worldwide have access to the life-prolonging medicines. Only about 100,000 of them live outside Europe, North America, Brazil, Australia or Japan.

As evidence mounts that proper use of antiretroviral drugs can actually offer a normal life expectancy, anger has mounted in the poor world, where most people infected with the virus die within years. Today governments, foundations and UN agencies are trying to bring the drugs - which cost upward of $10,000 a year in the United States - to millions of the poor around the world.

This month in the Bahamas 2,500 HIV patients are receiving care, 1,200 of them on medications provided free under the country's universal health care system. And by the end of 2004, the estimated 6,000-plus infected Bahamians will be in the health care system, said Ira Magaziner, director of the Clinton Foundation's AIDS program - perhaps half on antiretroviral drugs.

The island nation's 3.5 percent HIV infection rate is second highest in the Americas after Haiti, at 5 percent, according to UNAIDS. HIV made its way to the Bahamas during the early 1980s, via Haitian immigrants, national health experts say. The epidemic was fueled initially by cocaine trafficking,then prostitution.

A recent visit finds billboards lining the main byways of New Providence Island, warning, "No Sex, No AIDS. Know Sex, Know AIDS." Here, the face of HIV belongs to women like 28-year-old Natasha, who learned she was infected when she had a routine blood test.

"The baby's father was HIV-positive," Natasha, who asked that her last name not be published, said in an interview. "He travels a lot - all over the world. He's a pro pool player. So it's hard to say where the HIV came from."

And Shavonne, also 28 and pregnant, who has been HIV-positive since 1994. She, too, got the virus from a boyfriend who didn't tell her he was infected.

Shavonne has had two children since she became infected, not knowing if they might get the virus from her. Blood tests have shown that each is HIV-negative.

Natasha and Shavonne feel healthy today because they are on anti-HIV medications. And the Bahamas has become a model that South Africa and several other nations plan to emulate.

More than two decades into the disease, governments and international agencies are taking bold steps to treat millions of infected people in poor countries. The recent escalation is due, in part, to the role of Clinton, whose Harlem-based foundation has focused its energies on reversing the course of the scourge.

So far, the Clinton Foundation has been involved in South Africa, Mozambique, Rwanda and several Caribbean countries, helping draw up master plans for building up their health systems, distributing anti-HIV and anti-tuberculosis drugs, as well as providing financing for the efforts. At the heart of the foundation's efforts are negotiations with drug companies to reduce prices and development of a model for revamping a health care system, based on the Bahamas experience.

In the spring of 2002, "we met with leaders in several [African] countries," said Magaziner, a former White House aide. "They all told us that if we cannot solve the AIDS problem, we can't do anything else. So we went to the donor countries and said, 'Why aren't you funding treatment programs?' "

He said wealthy nations in Europe, North America and Asia were reluctant to provide funding due to concern that the poor countries lacked the capacity to distribute the drugs; that funds would wind up in corrupt hands; and that Africa would become a breeding ground for drug-resistant forms of HIV.

"So what we decided to do is we'll focus on treatment, go into countries, develop an infrastructure," he said. "We wanted to do scale-up in 10 countries, and build international models."

Clinton laid out his plans in an editorial in the New England Journal of Medicine last spring, saying, "Our intention is not to duplicate work but to build on existing plans and to ensure that these plans become operational. Once these plans are in place, I will help to raise the funds needed to implement them."

They started in the Bahamas.

Late last year, the foundation provided technical assistance, according to Dr. Linda Margherio of Harvard Medical School, a member of the foundation staff.

The first step was drug price negotiations, said Bahamian chief medical officer Dr. Merceline Dahl-Regis. In 2002, the Bahamas could afford to treat only 350 HIV patients, she said, all mothers and children, using a two-drug combination that cost $3,600 a year per patient.

Magaziner and Clinton intervened, negotiating price reductions with the Indian generic drug manufacturer CIPLA. The resulting triple-drug combination cost $493 a year - and made treatment possible for far more patients. Subsequent negotiations lowered the cost to less than $200 per patient annually.

The Clinton team decided to pursue a strategy that could reach beyond the Bahamas: a bulk purchase of the drugs.

"Because we knew we had these plans we were putting together [in the Caribbean, South Africa, Mozambique, Tanzania and Rwanda]," Magaziner said, "we went to drug companies and said, 'We're ordering for 2 million people.'"

Now he expects the cost to fall to below $100 per person annually. The foundation staff has gone "to raw materials suppliers, traced the whole chain of production [of the drugs] ... all the way through the factories," he said, showing the generic-drug manufacturers how to decrease their production costs and increase the output.

"The Clinton Foundation has handed a lever to other AIDS funders - the U.S. government and the Global Fund - to make their dollars go further," said Jamie Drummond, executive director of DATA, the AIDS-fighting organization started by rock star Bono.

The World Health Organization has also expressed gratitude for the foundation's initiative, and Doctors Without Borders has offered praise, saying it has "made feasible" the WHO's global campaign to get HIV treatment to 3 million people by 2005. Dr. Bernard Pecoul of Doctors Without Borders said he was particularly elated by the foundation's late October success in convincing generic manufacturers to combine three anti-HIV medicines into a single pill that can be taken twice a day - at a cost of 36 cents daily.

Further, he said, "if we didn't have the imprimatur of President Clinton, we couldn't have gotten the momentum."

In July, the foundation mobilized a team of 24 experts, drawn from Harvard, Columbia University, Johns Hopkins Medical School and the National Institutes of Health, to spend five weeks in South Africa to design a $1.5-billion plan to treat about 3 million people in that country by 2007. The nation's president, Thabo Mbeki, had ardently opposed distribution of the medicines - as well as the very concept that HIV causes AIDS.

"President Mbeki would never have struck the deal without President Clinton's influence, but the deal had to have follow-through," Magaziner said. Ultimately, the success of the Bahamas plan helped sway Mbeki, Magaziner said.

Spurred by the South African success, the foundation is now negotiating a similar role in China and India. "This whole initiative is possible because President Clinton is who he is," Magaziner said. "We can go to China and get sit-downs with [President] Hu Jintao and [Premier] Wen Jibao. We can go to South Africa and sit down with Mbeki. The doors open."

A year ago President George Bush called for treating hundreds of thousands of people in 14 poor countries through a five-year U.S. effort costing $15 billion. Congress has not yet allocated the funds, but the administration's Office of the Global AIDS Coordinator in the State Department has requested applications from companies, nongovernmental organizations and religious groups for delivery of prevention and treatment. Officials say they plan to have the program working by spring.

"They are working furiously to get this thing out the door, and get things implemented," Dr. Anthony Fauci, Director of the National Institutes of Allergy and Infectious Diseases, said in an interview. Last week [on Monday], Magaziner met with the State Department group to discuss the Clinton Foundation's experiences in the Bahamas and elsewhere. It was a cordial gathering, according to Bush administration officials. But the generic drug model will not be used by the Bush administration, they said, because there safety of the foreign-made products can't be guaranteed. Instead, the administration will aim to get discounted drugs from American manufacturers. Critics from the Doctors Without Borders charge that relying on the U.S. pharmaceutical industry will mean spending more money per patient. Administration officials declined to discuss that charge, insisting they prefer American-made products for safety.

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