Global Policy Forum

By Douglas Farah

ABIDJAN, Ivory Coast -- April was a happy month for Joseph Sama. For the first time in the six years he has known he has AIDS, his diarrhea subsided, the constant itching and flaking of his skin eased, breathing became easier, and he even added a few pounds to his almost skeletal frame. It was the month the 56-year-old cook could afford the $14 fee for the government-subsidized "cocktail" of antiretroviral drugs that can turn AIDS from a death sentence to a manageable chronic disease.

But in the past two months, despite being one of only 2,000 people enrolled in a special AIDS treatment program, Sama has been unable to afford the medicines, and his ailments have worsened. Only one of the seven adults in his household on the edge of Abidjan has a full-time job, and the cost of providing for six school-age children and the rest of the family left nothing for Joseph's medicine. "The children have needs, we have little money," said Sama, sitting on the cement patio of the family's small house and caressing the precious piece of paper that gives him access to the government program. "If I had the money, I could go right now and get medicine and feel better. But I don't have the money."

The case of Sama and millions like him in sub-Saharan Africa, home to 70 percent of the 36 million people worldwide who are infected with HIV, shows the overwhelming difficulty of providing treatment on this impoverished continent, despite dramatic drops in the price of antiretroviral drugs.

While AIDS experts agree that the steep price cuts recently enacted by some of the world's largest pharmaceutical companies were an important and welcome step, they say the move will have a limited effect until a host of other issues are dealt with. These include combating the grinding poverty that makes almost any charge unaffordable, creating a health care infrastructure to deliver the drugs and monitor their use, and educating people about AIDS. "AIDS here is not a medical issue," said Marc Aguirre, a doctor with Hope Worldwide who runs an AIDS clinic in Abidjan that deals with some of the country's poorest HIV/AIDS patients. "It is a developmental problem, linked to social and economic conditions. It is a poverty issue."

At the heart of the debate over providing antiretrovirals to Africa is the issue of whether a significant portion of international funding for the fight against AIDS should be devoted to expensive treatment for those who have the disease, or whether the world should continue to focus virtually all of its resources on preventing the spread of the disease in Africa. The United Nations, the United States and others have consistently emphasized the importance of prevention in Africa, but advocates of treatment maintain that the obstacles to effectively providing antiretrovirals can be surmounted.

Regional AIDS experts say that, as serious as the problems are in Ivory Coast, the country is still West Africa's most prosperous and has some medical infrastructure and government interest in combating and treating the illness, making it far better off than most others in Africa. "Ivory Coast has done well," said Abdoulie Janneh, assistant administrator and director for Africa of the U.N. Development Program, which helps coordinate regional AIDS strategy. Neighboring countries such as Liberia and Sierra Leone, which are riven by violence, remain "a nightmare," he said.

Last year, Ivory Coast was one of six countries in Africa to sign up for an initiative called "Accelerating Access," offered by leading pharmaceutical companies and brokered by the United Nations. In essence, in exchange for discounts of up to 90 percent on antiretroviral drugs, the countries agree to honor patent rights and to keep the medicine off the black market.

In January, President Laurent Gbagbo made the job of director of the National Fight Against AIDS a cabinet-level position, the only African head of state to do so, and has spoken out on an issue that is often taboo. After two years of political instability and a virtual halt in all government-funded AIDS education and prevention activities, Gbagbo budgeted $17 million for such efforts this year. "I refuse to just watch Ivorians die," Gbagbo said this month during an AIDS awareness program, at which he acknowledged that Ivory Coast's HIV infection rate of 11 percent could double in the next three years if left unchecked.

But those efforts are still not enough, and the numbers here are staggering. A study released last year by UNAIDS, a consortium of U.N. agencies that oversees international AIDS efforts, estimated that 40 percent of the nation's 15-year-old boys would die of complications from AIDS if the pandemic went untreated. If the AIDS risk were halved over the next 15 years, the study said, the rate would still be 25 percent. "Even if the drugs were free, it would not solve our problems," Kassim Sidibe, minister of the National Fight Against AIDS, said in an interview. "Health care access is a serious problem. There are no laboratories outside of Abidjan to administer and monitor necessary blood tests, and maybe 10 doctors in the country who know how to treat people with antiretrovirals. We have no follow-up capabilities. People don't get tested, so they don't know their HIV status. Cheap drugs are good, free drugs are better, but they are only a piece of the puzzle."

And they're likely to remain a small piece for at least several more years. A study released in April and signed by 128 members of the faculty of Harvard University estimated that only 10,000 of sub-Saharan Africa's 25 million HIV-infected individuals received antiretroviral treatment. The study concluded that "a rapid scaling up of scientifically monitored treatment in poor countries will prove feasible, affordable and highly effective." It estimated that the cost of increasing antiretroviral treatment to cover 1 million people -- including testing and building the necessary health infrastructure -- would be $1.1 billion a year for three years, or a little more than $1,000 per patient annually.

At a special AIDS summit in Abuja, Nigeria, in April, U.N. Secretary General Kofi Annan called on countries in the developed world to increase their spending on prevention and treatment of AIDS, malaria and tuberculosis in Africa to between $7 billion and $10 billion, and he proposed the creation of a global fund. But so far only a fraction of that amount has been committed. Terence Chorba, director of the Atlanta-based Centers for Disease Control and Prevention's office here, said there was a further complication for those who are fortunate enough to get the drugs.

Often, because of financial pressures, patients stop taking antiretroviral drugs until they feel severely ill again. Such intermittent use can create AIDS viruses that are resistant to the drugs. "We need to be judicious, and to be judicious we have to monitor patients, monitor labs, and that infrastructure doesn't exist," Chorba said. "Antiretrovirals are a major piece, but a lot of other major pieces also have to be addressed."

So, with the resources for antiretroviral drugs still far out of reach, much more common pieces of the puzzle are centers like Aguirre's small clinic in the poor Treichville neighborhood. Here, antiretroviral drugs are not an option because of their cost, but patients receive antibiotics, skin creams and painkillers to fight the diseases that attack people whose immune systems are ravaged by AIDS. Patients referred here by hospitals or other AIDS centers can get a free breakfast, counseling and some basic treatment in the tiny four-bed room -- all for $2 a month. Aguirre said many people cannot afford even that, so the fee is often waived. "There are competing priorities in families," said Aguirre, who has worked here for seven years. "Do you buy food for the family or medicine for one sick person? Or if the person is feeling better, they stop their medicine for a while to free up resources."

One recent morning, Sama came to the clinic to get some antibiotics from the one-room dispensary. "Some days are good and some days are not good," Sama said, gently lifting a bandaged, infected foot for which he sought treatment. "Every day, we do what we can."

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