Perspectives

Plagued by Apathy?

The Uneven Responses of Science and Public Policy to HIV and AIDS in Africa

As the world girds for the possibility of a bird flu pandemic, the HIV and AIDS pandemic marches relentlessly onward, almost lost in the background. But the numbers are mind-numbing: As of 2005, more than 40 million people worldwide were living with HIV. The brunt of the pandemic has fallen on sub-Saharan Africa, where more than 25 mil- lion people are living with the disease, over 6 million of whom are between the ages of 15 and 24.

As special envoy of the secretary-general of the United Nations for HIV and AIDS in Africa, former Canadian ambassador Stephen Lewis has crisscrossed the African continent, witnessed firsthand the pandemic’s grim toll, and written movingly about it in his book, Race Against Time. Speaking at RAND, he offered some provocative, sobering, and impassioned thoughts about how the race is going and what must be done to win it.

AP PHOTO/KAREL PRINSLOO   Pascazia Mukamana, left, holds her three-year-old sister Solange Muragishemaria, who displays symptoms of HIV infection, at their home in Rwanda in May 2003. Months earlier, Mukamana had quit school to raise three siblings after their mother had died from AIDS.

Beyond the “Silver Bullet”

Given the daily toll the pandemic is taking in developing countries and in sub-Saharan Africa in particular, “finding a vehicle or vehicles to break the back of the pandemic is imperative,” said Lewis. The best “vehicle” in scientific terms would be the discovery of a vaccine — the so-called silver bullet — but a vaccine remains as elusive as the virus itself, which Lewis described as having “an almost Machiavellian dexterity in manipulating itself in ways that elude scientific inquiry.” He noted that the consensus, even among the most optimistic, is that it will take ten years or more to develop a vaccine.

Potentially closer in time is the scientific formulation of a microbicide that women could self-administer, much as one would today’s spermicides, to prevent the transmission of the virus. “There is a full court press to see if microbicides can be discovered and made available to women in developing countries in the next four to seven years,” said Lewis. If such a microbicide is even 60 percent effective, it could save millions of women’s lives.

What makes the need for a microbicide so pressing is that women, particularly those between the ages of 15 and 24, are the most vulnerable to infection. “There is an almost Darwinian selection of women for disproportionate vulnerability,” said Lewis, explaining that 75 percent of young Africans who are living with the virus are women and girls. The end result is that the virus is “denuding the African continent of women and threatening whole societies, a catastrophe unlike anything in history.”

Halting Policy Progress

While the science for preventing transmission of the virus is still out of reach, much of the science for treating the disease is well within grasp. Science continues to search for ever-better antiretroviral treatments, but merely applying the science that already exists now in the developed world to the developing world could prolong lives.

Lewis gave a number of examples that show the promise of public policy. The cost of using today’s brand-name antiretroviral medications is too high for developing countries. But the Clinton Foundation has negotiated an arrangement with Indian drug companies to sell generic medications — an arrangement that has dramatically reduced prices for poorer countries. Similarly, the Clinton Foundation has also negotiated for a pediatric dose of HIV medications, which will help many of the world’s 2.3 million children who are living with the virus. Currently, half a million children die of AIDS every year.

Still, the broader potential of public policy remains largely unfulfilled, primarily when it comes to providing money to combat the virus. In July 2005, the leaders of the Group of 8 (Canada, France, Germany, Italy, Japan, Russia, the United Kingdom, and the United States) met at the Gleneagles Summit in Scotland and committed their countries to ensuring universal access to anti-AIDS drugs in Africa by 2010. But just eight weeks later, when the Global Fund to Fight AIDS, Tuberculosis, and Malaria — which Lewis considers the best financial vehicle to break the back of the pandemic — requested $7.1 billion, it received just $3.8 billion. Such ringing promises, according to Lewis, often end up as empty rhetoric.

“There is an almost Darwinian selection of women for disproportionate vulnerability.” The virus is “denuding the African continent of women and threatening whole societies, a catastrophe unlike anything in history.”

Lewis also sees a double standard when it comes to preventing mother-to-child transmission in developing countries. “We are using single-dose nevirapine that reduces transmission by up to 50 percent, but if we used full HAART [highly active antiretroviral therapy] during pregnancy as we do in the Western world, the level of transmission would be 1 percent or less.”

Another double standard relates to saving the mothers so that their surviving children will not be orphaned. Three or four years ago, Lewis met three pregnant women at a health clinic in Kigali, Rwanda. The women asked him: “We’ll do anything for our babies, but what about us?” While a strategy for treating not just the newborns but also their mothers has been the standard of care in the developed world for years, the ability to prolong mothers’ lives is just now slowly being put in place in some countries in Africa. Today, some 14 million children across the continent are orphaned by AIDS.

Stuck in Neutral

In the race against time, Lewis suggested that the developed world is an apathetic competitor. While both science and public policy continue to putter along, the pandemic is winning. The consequences are dire and much larger than the individual lives lost. None of the 2015 targets for the United Nations’ Millennium Development Goals will be met in Africa, said Lewis, in significant measure because the force of the HIV and AIDS pandemic has sabotaged the continent’s capacity to achieve them. Those 2015 targets include reducing extreme poverty by half and making primary school available for free to all children.

Without an extraordinary effort from all corners of the international community, he warned, the world will mark a very different kind of milestone in the near future. “At the present rate, we’ll have a cumulative total of 100 million deaths and infections by the year 2012.”