Wall Street Journal - July 1, 2004
Mark Schoofs, mark.schoofs@wsj.com

The program, operated by the Zimbabwean health ministry with help from the French group Doctors Without Borders, started in April. At the same hospital, the U.S. Centers for Disease Control and Prevention, or CDC, is also trying to help AIDS patients.

Together, these efforts encapsulate some of the hope -- and many of the challenges -- of turning Western aid money into real help for Africa's millions infected with HIV.

As of last week, 153 patients, including eight children, were receiving AIDS drugs at the clinic. But the waiting list of patients who are so sick they need the drugs immediately has swelled to about 300. Another 480 people have scheduled appointments to be evaluated by a doctor, filling every slot through the end of the year. Signs in the hospital announce that doctors won't see any new AIDS patients until January.

The Mpilo clinic, like many in Africa, is short of trained personnel. It has just one full-time doctor, though others come in part time. Doctors Without Borders says it plans to bring in more drugs for those who need them right away and more doctors for those who need to be diagnosed. Over five years it plans to treat 1,500 people with AIDS medication at the clinic. Zimbabwe has 1.8 million people with HIV, according to the latest statistics from the Ministry of Health.

At the clinic, a nurse from Doctors Without Borders recognizes a woman in a white sweater standing in a corner. As soon as the nurse greets her, the woman grabs her shoulder and starts crying. She just lost her child, almost certainly to AIDS. She has come to the clinic a day early to get antiviral drugs to take with her to the funeral.

The CDC has renovated much of the clinic and purchased computers for patient records, which have been handwritten and stored in well-worn file folders. It also provided tests for the AIDS virus. But Shannon Hader, who is in charge of the CDC's Zimbabwe operations, and her colleagues in Africa at the U.S. Agency for International Development have been trying for seven months to get antiviral drugs for the programs they oversee. "We had hoped the drugs would be here in March or April," she says.

In the storeroom of the Mpilo clinic's pharmacy, the painted wooden shelves on the right-hand wall hold drugs purchased by the Ministry of Health and the center shelves are reserved for Doctors Without Borders' drugs. The left shelves -- for the U.S. government's drugs -- stand empty.

Why the delay? Usaid assigned the job of purchasing drugs for the Zimbabwe program to John Snow Inc., a Boston-based contractor. Before Snow could answer the request of Usaid's employees in Zimbabwe for drugs, it had to obtain a waiver from agency headquarters in Washington because pharmaceuticals are a "restricted" item. The Snow employee in charge of procuring the drugs, Marilyn Noguera, says she got the waiver in November, but it was revoked three weeks later because she didn't have proof that the drugs she wanted to buy were made at factories with "good manufacturing practices." She spent five weeks getting the proof from five different drug makers.

After another month of waiting, Ms. Noguera was granted the waiver anew. Since then, she's been negotiating with drug companies. All of them have programs to cut prices for drugs intended for poor countries, but each one is different. Each purchasing contract has to meet U.S. standards for government supplies, and the negotiations continue to hold her up.

When the American-bought drugs finally do arrive, they're expected to cost more than twice as much as the drugs on the other shelves in the storeroom. Doctors Without Borders says it buys generic drugs from India's Ranbaxy Laboratories Ltd. at a cost of about $265 per patient per year. For the moment, U.S. regulations require Ms. Noguera to purchase brand-name drugs. She expects that together they'll cost about $581 per patient per year. A recent U.S. initiative might make it possible for Ms. Noguera to buy the cheaper copycat drugs, but no one is sure how soon.

Told of Ms. Noguera's troubles procuring the drugs, Randall Tobias, coordinator of global AIDS policy for the U.S. government, says he isn't familiar with the case but acknowledges that it takes time to get programs running smoothly. "We're still in the process, I'm sure, of getting the bugs out," he says.

At the clinic in Bulawayo, some people can't wait. Counselor Annah Phiri is HIV-positive herself. She knows how effective the drugs are, because once she started taking them a couple of months ago, a rash on her face cleared up and she felt much more energetic. She says one of her patients asked when he could start taking the drugs. She told him she didn't know, and recalls him saying, "We will die waiting for those drugs."

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