"Raise the Alarm Loudly"

Africa confronts the AIDS epidemic

by Akin Jimoh

Dollars and Sense magazine, May / June 2001

We were both standing on the sidewalk, watching the convoy of returning soldiers on their way to the military hospital in Victoria Island, Lagos, Nigeria. Amid the noise from the heavy-duty military vehicles and downtown traffic, my companion, Mohammed Farouk Auwalu, a former soldier in the Nigerian army, shook his head and muttered, "Many of them will most likely die soon or be out of the army like me with little or nothing to show for it. A lot of people don't know that many have died, others are dying, and many are walking in the shadow of death."

The convoy was returning from one of Nigeria's many peacekeeping missions elsewhere on the continent, but African wars were far from Auwalu's mind. He was talking about the specter of AIDS. In his mid thirties and married, Auwalu is now retired, not because he cannot perform his assigned duties, but because he is living with HIV. He currently heads the Nigeria AIDS Alliance, an awareness group formed by people living with HIV/ AIDS.

THE PANDEMIC

So far, AIDS has killed 17 million Africans. It has orphaned about 12 million children. And about 25.3 million

Africans (about 9% of the continent's total population) now live, like Auwalu, with HIV. According to the World Bank, the HIV infection rate in pregnant women in Blantyre, Malawi, increased from less than 5% in 1985 to over 30% in 1997. In Francistown, Botswana, the rate climbed from less than 10% in 1991 to 43% in 1997. New figures from the United Nations Joint AIDS Program (UNAIDS) show that 3.8 million people in sub-Saharan Africa became infected with HIV during 2000. Meanwhile, 2.4 million Africans died of AIDS that year.

From the Horn of Africa to the Cape of Good Hope, HIV/AIDS is crippling national economies. Many African countries now face the enormous costs of fighting the epidemic and caring for the millions orphaned by AIDS, even as the most productive generation is decimated by the disease. A study published in the South African Journal of Economics in July 2000 concluded that, as a result of HIV/AIDS, South Africa's national income would be 17% lower in 2010 than it would have been otherwise. Overall, the World Bank estimates that HIV/AIDS has cut economic growth in Africa by about two thirds.

"The AIDS situation in Africa is catastrophic and sub-Saharan Africa continues to head the list as the world's most affected region," says Dr. Peter Piot, executive director of UNAIDS. "One of the greatest causes for concern is that over the next few years, the epidemic is bound to get worse before it gets better." AIDS has struck virtually all sectors of society. Families have been devastated; husbands, wives, brothers, and sisters are dead or dying. Women, young people, and children are among the hardest hit.

How did it get this bad?

* Migrant labor. The prevalence of migrant labor in Southern Africa has greatly contributed to the high infection rates in Botswana, South Africa, Malawi, Namibia, Zambia, and Zimbabwe. As migrant laborers move from one work site to another, leaving their families behind, many engage in multiple sexual relationships.

* Low social status of women. Women account for half of Africa's HIV-positive population, according to the UN, and the infection rate for women is on the rise. Data from several African countries show infection rates for teenage girls five to six times the rates for teenage boys. Poverty forces many girls and women to trade their bodies for money. Meanwhile, the low social and economic status of women, argues UN Secretary General Kofi Annan, results in a "weaker ability to negotiate safe sex."

* Lack of open discussion. Cultural and religious inhibitions on the discussion of sex-related issues hindered AIDS prevention at an early stage. Repression against the media also inhibited the flow of information. At an HIV/ AIDS meeting in Mexico in 1988, U.S. journalist and science writer Laurie Garrett saluted by name a Kenyan journalist who had broadcast AIDS information over an independent radio station. He was arrested within hours. The Zimbabwean and South African governments have also routinely targeted journalists disseminating information about AIDS.

* Lack of quick government action. Olikoye Ransome-Kuti, a pediatrician and former health minister of Nigeria, says that, even in the mid 1990s, the Nigerian military regime allocated a mere $3,000 annually to AIDS control programs. Now, 5.4% of Nigerians between the ages of 15 and 49 - about 2.6 million people - live with HIV/AIDS. In many African countries, political turmoil and war contributed to a delayed government response.

* Weak health-care systems. In the mid 1980s, most African countries achieved child-immunization rates, to take just one indicator of basic public-health provision, of over 80%. In the following decade, rates fell below 20% in many African countries. Lack of access to basic health services has increased the rate of non-sexual (mother-to-child) HIV transmission.

* Economic austerity programs. The AIDS epidemic began its full onslaught in the mid-to-late 1980s, when the International Monetary Fund imposed structural adjustment programs (SAPs) on many African countries. Under the SAPs, national currencies were devalued and subsidies to critical sectors of the economy discontinued. With minimal funds available to governments, social infrastructure and services, including health services, suffered. Keith Hansen, deputy head of the World Bank's AIDS Campaign Team for Africa, admitted that SAPs had weakened African economies. Austerity has deprived African countries of the means to fight the epidemic.

* The high cost of drugs. Pharmaceutical companies like Bristol-Myers Squibb of the United States, GlaxoSmithKline of Great Britain, and Boerhinger Ingelheim GMBH of Germany sell their patented AIDS drugs for $10,00015,000 per patient per year, three to five times the per capita income or South Africa (the highest in Africa).

Uganda, the place where AIDS first struck in Africa, now offers a model for combating the epidemic. The Ugandan government has helped bring about a mini-sexual revolution. In the mid 1980s, it began prevention campaigns on HIV/ AIDS and other sexually transmitted diseases, and started promoting sex education generally. President Yoweri Museveni personally championed the AIDS-control program. Meanwhile, some debt relief and the creation of an anti-poverty program has resulted in a revival of the health system.

"When a lion comes to your village you must raise the alarm loudly," Museveni says. "This is what we did in Uganda; we took it seriously and achieved good results. AIDS ... is not like small pox or Ebola. AIDS can be prevented as it is transmitted through a few known ways. If we raise awareness sufficiently, it will stop." Between 1997 and 2000, while the HIV infection rate climbed from about 13% to nearly 20% in South Africa and from about 25% to over 35% in Botswana, it has actually decreased in Uganda, from 9.5% to 8.3%. Since there is no cure for AIDS, lower infection rates reflect the deaths of some people who already had AIDS - but also a lower rate of new HIV infections.

THE PATENTS WAR

In Pretoria, South Africa, this past March, thousands of AIDS activists and HIV-positive youths descended on the country's High Court and the U.S. Embassy. Wearing "HIV-positive" T-shirts and baseball caps, hands locked together in solidarity, they marched in angry protest against the high cost of AIDS drugs. Their placards expressed their rage: "Lives Before Profits" and "AIDS Profiteer Deadlier Than The Virus." The battle over AIDS-drug patents had begun.

A new cocktail of generic AIDS drugs developed by the Indian drug company CIPLA threatens the big drug companies' lucrative monopolies. CIPLA has offered the drug at a cost of $350 per year per patient to the humanitarian organization Doctors Without Borders, and $600 per year per patient to African governments. In March, thirty-nine of the big pharmaceutical companies went to court to challenge the South African government's go-ahead on the sale of generic AIDS drugs, provoking the March protests.

A few weeks after the court battle began, Doctors Without Borders approached Yale University to convince it to release its patent on the AIDS drug dT4. Two Yale professors had developed dT4, which the University then licensed to Bristol-Myers Squibb. Professor William Prusoff, one of the developers, wrote during the height of the controversy that the drug should be either free or very inexpensive in sub-Saharan Africa, and expressed disappointment that it was not reaching the millions of people who desperately needed it. Not long after, Bristol-Myers announced that it would reduce the cost of d4T by 15% in the United States and 85% in the rest of the world, and that it would offer the drug for 15 cents per daily dose in the most afflicted areas of Africa. The other two pharmaceutical giants, GlaxoSmithKline and Boerhinger Ingelheim GMBH, are also expected to cut their AIDS-drug prices. The companies, however, remain steadfast about keeping their patent rights, which would leave ultimate control over prices and availability in their hands.

In response, the AIDS-devastated countries of Africa may resort to "compulsory licensing," ignoring the patents and proceeding with generic drugs. International convention recognizes the right of countries in states of national emergency to obtain or manufacture generic drugs, even in breach of drug-company patents. So far, President Thabo Mbeki of South Africa has resisted an official declaration of national emergency, though he promises to go forward with generic drugs. The U.S. government, under both former President Bill Clinton and current President George W. Bush, has promised not to challenge laws passed by African countries to improve access to AIDS drugs, even if U.S. patent laws are broken. It has not, however, pressed U.S. pharmaceutical firms to renounce their patent rights - which is why protestors targeted the U.S. embassy.

The battle is far from over. Even at 15 cents per day, or about $55 per year, AIDS drugs will remain beyond the means of most Africans. At the 8th Conference on Retroviruses and Opportunistic Infections in February 2001, doctors, scientists, and policymakers proposed that rich nations pay for drugs and other means to combat AIDS in Africa, with the United States paying $3 billion. Harvard economist Jeffrey Sachs explained that $3 billion would only cost the United States about $10 per person, the cost of a movie ticket and a bag of popcorn. Dr. Peter Piot of UNAIDS believes that this additional $3 billion would go a long way towards coping with the epidemic in sub-Saharan Africa - with half going to basic care for those already infected, the other half to prevention efforts.

Donors cannot, however, dictate how the battle against AIDS will be fought. A recent report issued by the Africa-America Institute, which champions a greater U.S. commitment to the fight against AIDS in Africa, concludes that donors need to support national priorities set by Africans themselves. Local circumstances vary greatly from country to country, the AAI argues, so international

donors need to learn more about Africa and adapt their programs to the needs of each country. "If the U.S. and other donors want to make a difference in the fight against HIV/AIDS in Africa," AAI President Mora McLean says, "they need to listen to Africans and involve them as full partners in the global battle against the epidemic."

Akin Jimoh is a Nigerian science and health writer and a Knight Science Journalism Fellow at the Massachusetts Institute of Technology (MIT) in Cambridge, Massachusetts. He holds two masters degrees, in medical physiology and public health, and has been involved in HIV/AIDS and development work for over 10 years. He is also the program director of Development Communications, a media service nongovernmental organization (NGO) based in Lagos, Nigeria.

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