San Francisco Chronicle - Monday, June 5, 2006
Sabin Russell, Chronicle Medical Writer

Remarkably, 2,400 of them are currently taking antiviral drugs, most of it supplied by the Ugandan health ministry with money from international programs. Three years ago, these life-sparing medications were available only to the fortunate few.

For Dr. David Bangsberg, a UCSF epidemiologist who divides his time between Uganda and San Francisco's Tenderloin district, the transformation in Mbarara has been stunning, but is still incomplete.

"They are putting new people on treatment every day, but there is still a waiting list of three to four months," he said.

Mbarara, with its university clinic, has been among the first Ugandan towns to benefit from a rush of international money for treatment. But even in Uganda, with the most ambitious program of any African nation to provide AIDS drugs, about half the 148,000 people who need antiviral drugs to survive have no access to them.

Outside Uganda, the situation is bleaker. Of the 38.6 million people worldwide estimated by the United Nations Joint Program on HIV/AIDS to be infected by the virus, 6.5 million need the drugs to survive. Yet the medicine is available to only 1 in 5 of them.

To activists who have been pressing to bring inexpensive AIDS drugs to Africa since 1999, the progress is imperfect, and bittersweet.

Northeastern University law professor Brook Baker, a policy analyst for the Health Gap Coalition, said history will show that the drugs could have reached millions more Africans, and saved millions of lives, had the West acted sooner. He blames foot-dragging by international drugmakers, and what he said is the U.S. government's obsession with protecting drug-industry patents.

"We know that efforts were made, mostly private and in the backroom, to get the pharmaceutical companies to respond to the pandemic with lower prices for antiviral drugs," Baker said. "They said flat out, 'No.' "

It was only under the pressure of activists -- with the help of Indian drugmakers who discovered they could make the drugs for a fraction of the Western selling price -- that drugmakers began offering steep discounts to the developing world in 2001.

Two years later, the World Health Organization set a goal to treat 3 million people in poor countries by the end of 2005. However, the initiative failed because, as Baker concedes, of a failure of political will, not only among wealthy countries needed to pay for it, but also among governments such as South Africa, Nigeria and India, where the response to AIDS remains lackluster.

"There is no doubt that the lack of commitment in developing countries is equally shame-worthy and equally problematic," he said.

For instance, South African President Thabo Mbeki, who even now entertains unorthodox views about HIV as the cause of AIDS, has done little to speed treatment to that nation's 5.5 million people living with the virus, despite government pledges to provide access to antiviral drugs.

"It is heartbreaking to think of the potential South Africa had to be the leader in bringing antiviral drugs to the continent," Baker said.

To Dr. Mark Dybul, acting U.S. Global AIDS coordinator in charge of President Bush's emergency AIDS relief program, the progress, though, has been remarkable. "The difference in Africa now is not just the money. The difference is hope," he said.

He contends that advocates for bringing antiviral drugs to the poor often underestimate the challenge. Generic drugs can bring the price of the medicines to $300 a year or less, but studies from Haiti show that the average annual cost of treating a patient is $1,600 when distribution, monitoring, personnel and drugs to treat related conditions are brought into play.

There is a growing recognition that efforts to bring AIDS drugs to the world's poor is limited when a nation's decayed health-care infrastructure cannot provide even simple hydration to infants dying of diarrhea.

"The things we had in San Francisco don't exist in much of Africa," said Dybul, who once treated AIDS patients in the city. "You assume communication among doctors. You assume a supply chain, a system for logistics. You assume there is financial management in hospitals. You assume there is waste management in hospitals. ... You assume there are hospitals."

Dybul said that the vast scale-up needed to provide drugs for tens of thousands of patients poses problems different from those uncovered in pilot projects -- but he insists that tangible progress is being made.

Dr. Paul Zeitz, executive director of the Global AIDS Alliance in Washington, agrees with Dybul that the impact of international efforts to provide antiviral drugs has begun to make a difference.

"I just returned from Zambia," Zeitz said recently. "Six years ago, there were 50 people on treatment. Three years ago, there were 3,000, and people were still running out of meetings to go to funerals.

"This visit, there were 50,000, and there is a national infrastructure to roll it out to the rural areas. That is a phenomenal transformation in that time frame."

Zeitz has been traveling to Zambia since 1994, and has been an eyewitness to the ravages of the pandemic on that nation. He said the new emphasis on HIV care is causing a strain on a medical system ill-equipped to battle less-dramatic health care problems.

AIDS is underscoring a fundamental weakness in public health infrastructures wherever it strikes, Zeitz said. Yet the international response to the pandemic has charged him with optimism.

"I actually felt like we are about to turn the tide on HIV in Zambia," he said. "If we can do it there, we can do it anywhere."

E-mail Sabin Russell at srussell@sfchronicle.com.
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