San Francisco Chronicle - July 12, 2004

For more than 20 years, health experts and world leaders have understood this peril, but a U.N. study shows the problem is deepening as AIDS kills millions and infects a younger generation.

Beyond the numbers, there is a deeper dilemma. It is within the world's grasp to curb AIDS -- or lose the fight entirely. Drug treatment and prevention programs hold the promise of improving a bleak picture. The situation isn't hopeless, if the political will can be found to address it.

For years, the twin goals of prevention and treatment seemed unattainable. Money, ideology and bureaucracy stymied progress as AIDS cases spiraled upward -- as the disease began to spread into new demographic groups.

But international efforts are now at a turning point. Prevention plans have flattened the upward curve of infection in poor countries, such as Uganda, Thailand and Cambodia, and in wealthier ones, such as Brazil.

In these places, there is no single answer. Education through billboards, schools and pop music plays a role. So do condom giveaways, abstinence programs, needle exchanges and a frank directive about "zero grazing,'' a reference to African slang for sex outside of marriage.

Emulating these programs isn't simple. After announcing a broad AIDS initiative in his 2003 State of the Union address, President Bush waited until last month before endorsing condom use, a problem area for many of his conservative supporters.

In other countries such as India with a growing AIDS population, open talk about sex and drug use clashes with cultural traditions. China, which fumbled the onslaught of the SARS outbreak, again is acting far too cautiously in attacking AIDS. If these two giant nations fail to stem its spread, AIDS will have a firm grip on a region with more than 2 billion people.

Money is also a crucial factor. A worldwide AIDS conference beginning today in Bangkok will take up generic drugs, a divisive topic that puts the White House on the wrong side of an important issue. Anti-retroviral drugs, which can extend life for years and tamp down agonizing symptoms, have dropped in price through generic copies of more costly patented brands.

For years, drugmakers have fought the obvious imperative to crank out cheaper pills as though AIDS medicine was no different than other medications. There were claims that there are too few doctors and nurses to dole out the medicine, patients didn't understand the regimen, and the knockoff drugs were of low quality.

But new studies show that complex dosages can be combined into cheap one- a-day tablets with positive results. Now drug companies are pushing for trade laws barring countries from producing generics.

This impasse can't continue. There must be allowances for drugs that can stem the world threat of AIDS, especially as cheaper medicine comes within reach of the most affected and impoverished countries.

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AIDS by the numbers

From its start in the 1980s as a gay men's disease, AIDS has jumped to a worldwide epidemic that has killed 20 million and infected another 38 million.

The disease is now split between the sexes nearly equally. HIV, the virus that leads to AIDS, is the leading cause of death worldwide for those between the ages of 15 and 59. Half of the AIDS dead last year were under15 years old.

No group is untouched. AIDS is spread by sex, both gay and straight, and intravenous-drug injections. These paths have led it around the world: China and India, the two biggest nations, which long ignored the problem, have cases in the millions.

The bill for prevention and care will be enormous. In 1996, AIDS spending was $300 million worldwide. By 2007, the U.N. AIDS program estimates $20 billion will be needed. Last year, $5 billion was spent.

There is no vaccine that can stop AIDS. But there are drugs that extend life and quell symptoms. Generic copies of costly drugs have the potential to cut billions in expenses and have led the United Nations to push a "3 by 5'' plan to provide drugs to 3 million individuals by 2005. Drugs are the high- tech end of the medical-supply problem. Condoms are the low-tech end.

There's a shortage of condoms, an essential part of prevention programs. Right now, demand exceeds supply by 40 percent, and U.N. AIDS experts predict19 billion will be needed by 2015.

Spending per AIDS patient in the United States is 1,000 times the per capita spending in Sub-Sahara Africa, according to U.N. figures. In 2003, 14, 000 died from the disease in the United States compared to 3 million worldwide.

One or both parents of an estimated 12 million children in the Sub- Saharan Africa have died of the disease, threatening family stability, school and job prospects. The region of 48 nations has 25 million AIDS cases, by far the most of any area. In six of these countries, AIDS has claimed more than 20 percent of the population.

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The good and the bad

In fighting AIDS, some countries succeed while others fail. Here are a several examples and the reasons why.

The successes:

Thailand: Notorious for its wide-open sex tourism, the country has capped a feared AIDS explosion.

Health and civic leaders went on a condom campaign, distributing them in bars and brothels. Prostitutes insisted that all customers use them. There's even a small restaurant chain, "Cabbages and Condoms,'' that popularizes the items. Bangkok's reputation hasn't changed though AIDS prevention has.

Brazil: A determined campaign plus heavy use of life-extending drugs has lowered its infection and death rates.

The government encouraged the use of copy-cat drugs of expensive originals, infuriating pharmaceutical firms but aiding the infected. An extensive education program was also launched to warn citizens about AIDS transmission.

Uganda: Surrounded by countries with the highest infection rates in the world, tiny Uganda stabilized the AIDS epidemic. It's credited with pushing the "ABC'' plan: practice Abstinence, Be faithful and use Condoms.

The failures:

South Africa: When Nelson Mandela stepped down as president, his successor, Thabo Mbeki, was poised to be Africa's next great leader. No longer.

Mbeki disputed the source of AIDS, brushed off suggested prevention plans and obstructed public health efforts while AIDS spread. Now South Africa has the most HIV and AIDS cases: 5.3 million people or 1 in 5 adults are infected.

India: Indian drug firms make the cheap generics sought by AIDS agencies. Yet its central government is only now awakening to problem in its midst: close to 5 million cases. A conservative culture and stigmatized underclass of AIDS patients -- prostitutes and gays -- has led to inaction.

Russia: With its extensive health-care system and comparative wealth, Russia should rank with other European countries in tamping down AIDS. But the disease mainly has struck drug addicts, a marginalized group with no clout. As drug users go to prison and grow sicker, they've contracted tuberculosis, which has spread to the non-AIDS population.

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