The Wall Street Journal - Friday, 27 December 1996.
Amanda Bennett, Staff Reporter of The Wall Street Journal

But here in Africa, where AIDS has taken a far greater toll, experts are finding new hope in an old warhorse: the common antibiotic.

Antibiotics can't cure AIDS. But they can be used to treat many sexually transmitted bacterial diseases that make people far more likely to contract and transmit HIV. So if doctors can cure more cases of syphilis, gonorrhea and similar illnesses, they are likely to reduce the number of people who will eventually develop AIDS.

This approach, considered one of the first real advances in treating the spread of AIDS in Africa, is born of both frustration and success. Over more than a decade, aggressive prevention programs have made only modest headway. Yet, in villages that hug the shores of Lake Victoria, a research team recently cut the rate of new HIV infections about 40% simply by giving clinics enough drugs and trained workers to treat anyone with symptoms of a sexually transmitted disease.

Now, Tanzanian health workers are applying those methods to most clinics in the region and are making plans to expand to the entire country. Just across Lake Victoria in Uganda, the U.S. Agency for International Development is spending up to $6 million over five years to train workers in treating sexually transmitted diseases. In addition, $10 million from a World Bank loan has been earmarked to supply drugs to USAID's project.

Some experts are studying more radical possibilities. In the Rakai district of Uganda, a group sponsored by the Ugandan government and by Johns Hopkins and Columbia universities is providing antibiotic treatment to virtually every adult -- sick or well -- in 26 rural communities. "We are testing with an intensity that has never been done before," says Maria Wawer, a Columbia public-health professor who is directing the project.

Many researchers believe the strategies being tested here could save thousands of lives elsewhere in Africa, as well as in other Third World areas where AIDS threatens to explode into similar epidemic rates. "It's probably the most attainable, effective way to diminish HIV transmission" in the general population, says John Cutler, an epidemiologist for USAID in Uganda.

Officials at the agency believe that by rigorously treating sexually transmitted diseases, they could cut new HIV infections by 10% to 20%. Others have higher expectations: "I'm hoping we could cut HIV transmission in half over five to 10 years," says Fred Wabwire-Mangen, a public-health official associated with the Rakai project.

Yet for all the enthusiasm, there are formidable obstacles. No one is sure that results obtained in these experiments can be replicated on a broader scale. While antibiotics cost a fraction of the protease-inhibitor combinations pioneered in the U.S., even common drugs are out of reach for most people in places like Mwanza, where a tin roof is a sign of wealth.

Of greater concern, certain sexually transmitted diseases are already resistant to many ordinary antibiotics, and researchers worry that a widespread distribution program could make the drugs even less effective. "Lots of antibiotics flying around can breed lots of different problems," says David Serwadda, an epidemiologist with the Rakai project.

Still, many experts say the risk is worth taking -- especially with no effective alternative in sight. The longed-for AIDS vaccine is still just a dream. Even if a vaccine were to be developed soon, it would be years before it could be widely distributed. And the protease inhibitors that have produced dramatic results in the U.S. aren't an option in Africa; they are far too expensive and require a more developed health-care system.

The antibiotic approach comes after years of trial and error. Doctors have long been mystified by AIDS's explosion in Africa, where the virus cut a wide swath. In Mwanza, more than half the 450-bed general ward at Bugando Hospital is filled with AIDS patients. In Uganda, when project staffers ask for time off, "we just presume that it's to attend a funeral," says epidemiologist Lynn Paxton.

Overall, nearly 6% of all sub-Saharan Africans are infected, and almost two-thirds of the world's HIV cases are found here. Also, HIV transmission here is overwhelmingly heterosexual -- more than 70%, by most estimates.

In the U.S., most of those infected are men who have sex with men, intravenous drug users and the sexual partners of those groups. Still, experts have worried that the pattern of heterosexual transmission would become the norm in the developed world. Indeed, a widespread American public-health campaign in the late 1980s was based at least partly on that fear.

Few realized, however, just how prevalent sexually transmitted infections were in much of Africa. When researchers in Rakai did widespread tests, they found that nearly 10% of adult villagers had active syphilis. Nearly a third of the men and a fifth of the women had signs of having been exposed to chancroid, a bacterial infection that causes genital sores. More than 60% of the women had a vaginal infection.

How do genital infections increase HIV transmission? Many of the diseases create breaks in the skin through which HIV can more readily pass. But even without sores, genital infections can cause individuals to pass virus more readily to their partners.

A study in Malawi, for example, showed that HIV-positive men who also had urethritis, an inflammation of the urethra, had more than seven times as much HIV in their semen as did HIV-positive men who didn't have other infections. After treatment for the inflammation, their HIV concentration dropped significantly. Infections may also increase an individual's susceptibility to HIV by flooding the genital area with white blood cells that become targets for the virus.

In Tanzania, research into the links with AIDS got under way in 1991. Experts did HIV tests on about 12,000 adults in six pairs of villages around Lake Victoria. Four pairs of villages were rural, where people farmed cassava and bananas. One pair involved fishing communities on islands, and another pair was on major trucking routes. Of each pair, one village received greatly improved services for sexually transmitted diseases while the other got standard treatment.

So, for example, in Sangabuye, a fishing village about 90 minutes north of Mwanza via a deeply rutted road, clinic officer Mkama Magoti continued treating gonorrhea as he always did, by prescribing a two-day course of penicillin. Such a course was standard here in the 1960s and 1970s but isn't as effective as newer treatments. What's more, he didn't always have adequate drug supplies. Thus, he says, fewer than half the people he treated got better.

Meanwhile, in its paired village of Katunguru, a short ferry ride away, researchers trained clinic officers to recognize and treat symptoms of sexually transmitted disease according to a rigid regimen. They also made sure that clinics had ample supplies of penicillin, as well as more modern antibiotics like ciprofloxacin for treating stubborn cases.

At the end of two years, 1.9% of those in the six unimproved communities had become newly infected with HIV, while only 1.2% of those in areas receiving extra treatment had become HIV-positive. Each of the six treated villages had a lower rate of new infections than its paired village. Researchers found no significant differences in behavior among the villagers, and condom use remained low.

Now, as the project is being expanded, Mr. Magoti and his counterparts in the original control villages have received a three-week course in treatment methods. Sangabuye is also receiving regular shipments of antibiotics. Mr. Magoti says he now can heal more than 90% of those treated for venereal disease.

In the nearby Rakai district of Uganda, the 12,500-person project under way is even more ambitious. Researchers interviewed nearly every adult in 52 villages, tested them for infection for HIV and other sexually transmitted diseases and divided them into two groups. Every six to eight months, a team of health workers visits each village, reinterviewing, retesting and, over the course of two days, dispensing a handful of drugs to every adult -- sick or well -- who consents.

In one set of villages, the drugs are high-intensity antibiotics that cure most sexually transmitted bacterial diseases in a two-day combination. In the other villages, people receive vitamins and drugs against common intestinal worms. Villagers aren't told which medication they are receiving. (Still, anyone who shows signs of syphilis or who complains of other symptoms is directed to seek local treatment.)

On one recent day, more than a dozen health workers, equipped with rubber gloves, syringes and laboratory slides, fanned out through the farming village of Kasambya. Researcher Jane Namata trudged down a dirt lane to meet Robinah Namakula, a farmer taking a midday rest. Spreading out a plastic raincoat on the ground, Mrs. Namata turned the banana grove into a makeshift clinic.

She asked a raft of questions about Ms. Namakula's health, marital status and sexual partners, then took urine, blood and vaginal samples. Finally, she gave Ms. Namakula a small handful of pills.

Throughout the day, other researchers met subjects in streets, gardens and mud-and-wattle homes. One woman said her husband might have been exposed to HIV. Another complained of genital sores.

Eventually, researchers will compare the number of new HIV infections in both sets of villages. Because over 90% of adult villagers have consented to be tested and treated at least once, this study is expected to show the effect of antibiotic treatments on a mass scale. In the earlier Mwanza study, people were treated only when something bothered them, so villagers who didn't have or didn't recognize signs of sexually transmitted diseases didn't get special treatment.

Many here don't experience symptoms, or if they do, don't feel they are anything unusual. "You go through your entire life thinking that discharges are normal," says Dr. Wawer, the project director. "Your mother has one, your aunt has one -- you think it's part of being a woman."

With sexually transmitted diseases so prevalent, mass treatment may be more effective than clinic treatment. It is also more costly, so it isn't clear how it could be applied on a large scale.

Even improving clinic services will be complicated, health workers are discovering, as they move from research to practice in Tanzania.

During the Mwanza study, researchers supplied their own drugs. Now, drugs are supplied through the less efficient Tanzanian government system. Sometimes, clinics get big supplies of one drug but not another, which hampers treatment since some medications must be given in precise combinations. In Uganda, meanwhile, World Bank funding for drug purchases has been approved for nearly two years, but few drugs have been dispensed because of a ponderous bidding process.

Moreover, in places like Tanzania, where until recently a bar of soap was a nearly unattainable luxury, antibiotics can become currency. Some corrupt health workers withhold treatment and demand money, or a few chickens, for a dose of drugs, says Ezra B. Mwijarubi, a researcher with the Mwanza project. To control that, clinicians must keep a log showing exactly who was treated for what condition with what drug.

Because medical clinics are often far away, many villagers choose traditional healers with herbal or spiritual remedies. Some head for a private pharmacy where they buy drugs one tablet or injection at a time -- a practice that can lead to antibiotic resistance. "They say: `Give me a shot today and maybe I'll be back tomorrow,'" says Clara Mayala, a health worker with the Mwanza program.

Too, a rickety system makes treatment hard. At the Sangabuye clinic, the labor and delivery facility is a table covered with ripped red oilcloth; a wasp nest hangs in the corner. While Mr. Magoti, the clinic officer, says he is allotted adequate medication for sexually transmitted diseases, he regularly gets less than a quarter of the malaria medicine his patients need.

Also, it is hard to beef up just one part of health care -- especially in areas where so many other deadly diseases are rampant. The top 10 recent health problems of the region are posted on the wall of the Sangabuye clinic. Sexually transmitted diseases are listed fourth, after malaria, respiratory-tract infections and dysentery.

Thus, AIDS workers believe that some drugs will be diverted to other needs. "If antibiotics are limited, you're not going to use them to treat sexually transmitted diseases," says Rowland O. Swai, who heads Tanzania's AIDS control program. "You're going to use them to treat a baby dying of pneumonia."

Then there is the problem of resistance. Many antibiotics must be taken over a period of seven to 10 days; a failure to follow through on the entire dose can leave a patient still infected, while enabling the bacteria to develop a resistance to the drug. Moreover, because other diseases are so common in Africa, there is a risk that they might also become resistant to common antibiotics.

The high-intensity antibiotics being used in the Rakai project minimize that risk. Such drugs are effective, but may be too expensive to be used on a wide scale.

Where does this leave the more traditional programs of condom distribution and safe-sex education? Such programs have had a big impact on AIDS transmission in certain places, notably in the gay community in the U.S. and among prostitutes in Thailand. Some say they should be expanded here.

"Treating a small number of people for sexually transmitted diseases isn't going to make a big difference if people continue to have multiple sex partners and aren't aware of the risk of HIV," says James Curran, dean of the School of Public Health at Emory University in Atlanta. "Condoms are so cheap . . . I wouldn't take money away from condom education," he says.

Such education is clearly needed. Researchers in Uganda and Tanzania say that regular condom use in the general public, while growing, is still far too low to have much effect.

Peter Piot, head of the United Nations' AIDS prevention group, says such results demonstrate that no one strategy will work everywhere. Still, he believes that aggressive treatment of sexually transmitted diseases makes sense, especially in places like sub-Saharan Africa: "Common sense tells us our evidence is good enough. Let's go for it."

And even if the real-world effects aren't as dramatic as in the studies, the treatment can still have an impact. "It won't have 40% effectiveness in real life," says Phillipe Mayaud, manager of the Mwanza project. "But in a desert, a bucket of water is something."

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