Wall Street Journal - November 20, 2003
Bill Clinton*

Yesterday's decision by the South African cabinet to approve a plan for the nationwide treatment of people living with HIV and AIDS is a milestone for a country that has one of the highest rates of HIV infection. Under the terms of the new treatment program, developed by the health ministry with the support of my foundation, up to 1.4 million South Africans should be receiving medicines which will extend their lives by years.

That is a big deal because, until now, of the more than 4 million people in sub-Saharan of Africa currently in need of medicine, only about 50,000 are receiving it.

President Thabo Mbeki and his government deserve a lot of credit for bringing this historic moment about. South Africa, for many years, has had one of the world's best programs for educating people about the dangers of AIDS, preventing people from becoming HIV-infected and promoting good nutrition to suppress the progression of the disease. Now, thanks to Mr. Mbeki, South Africa is showing leadership in the treatment of people already infected. Nothing less than the future of Africa is at stake. AIDS is causing incalculable damage to the health, economy and security of societies where the disease is allowed to run rampant.

Three hurdles had to be overcome before a nationwide treatment program could go forward. First, the price of antiretroviral medicines had to become more affordable. My Foundation recently announced an agreement with four generic drug manufacturers to cut the cost of ARVs dramatically, to as little as 36-38 cents per day, as compared to thousands of dollars per person per year in the developed world. South Africa's decision to be a large purchaser of ARVs itself will help make further price reductions possible. As treatment expands in South Africa and elsewhere, additional cuts may occur as well.

Second, any AIDS treatment program had to meet what Mr. Mbeki calls "the gold standard" of quality. South Africans had an unfortunate experience with a rapid rollout of TB drugs, when a failure to adhere to high standards led to the quick development of drug-resistant strains that made the disease worse. The plan approved yesterday incorporates quality standards which will not only help ensure that medicines are delivered and used in a safe and effective manner, but will also help reassure South Africans that the care they're being provided is equal to that given people in developed countries.

The third hurdle was one inherited from the apartheid era. South Africa still has great inequalities in its health care systems. Around cities like Cape Town and Johannesburg, South Africa has medical centers that rival any in the world. But these serve only a small percentage of South Africa's people. Most still must cope with a public health system that, while much improved since 1994, is still inadequate.

Among the rights guaranteed the people of South Africa by their post-apartheid constitution is the right to receive equal access to health care. That means an AIDS treatment program cannot begin with a small "pilot" project, or be established first in one community before being expanded to others. While there may be some short-term cost savings to a slow, small scale rollout, there can also be a perception of favoritism, depending on which people or locations are chosen to receive treatment first.

The AIDS treatment plan envisions nationwide distribution of ARVs, bringing the medicine to rich and poor alike. It is a more difficult logistical challenge, but it will also save more lives in the short- and long-term, with concomitant economic, security and social benefits as well. The plan also invests significant resources to improve the health system overall, particularly in historically underserved areas. Because of that, progress against other diseases, like malaria, is likely, too.

Despite clearing these hurdles, others remain. Creation of a nationwide treatment system requires careful administration of the drugs, a systematic program of testing and monitoring of patients, a major effort of community mobilization and many support services. It is also expensive even with the lower drug prices. And South Africa is committed to paying for this program out of its own government budget in order to ensure that it is sustainable.

But that long journey is now underway, with a very big step. Thanks to the courage and commitment of Mr. Mbeki, South Africa will be the first large country with a high HIV infection rate to put in place a comprehensive AIDS treatment program. In so doing, the government and people of South Africa will be able to help slow the global rate of death and debilitation caused by AIDS as well as the rate of new infections. And their experience will provide valuable lessons -- even a model -- for other large nations like India and China, once they embark along this very important path.

*Mr. Clinton, former president, is head of the Clinton Foundation.
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