Wool over the Eyes

I'm not an expert on AIDS, but I know enough to be dismayed by the comments of South Africa's health minister in a recent BBC news story on a conference on HIV and AIDS held earlier this month in Durban, South Africa. The conference was about the HIV/AIDS-hunger nexus and how food insecurity contributes to the spread and impact of AIDS. But what I heard from the health minister, Manto Tshabalala-Msimang, was: If you eat right, you're safe from HIV and AIDS.

Perhaps I misheard. When pressed for a statement on the role of anti-AIDS drugs, however, she was dismissive. I couldn't help thinking that she really believes people infected with HIV can eat their way out of its death sentence.

According to the Joint United Nations Programme on HIV/AIDS, among South Africa's 44.8 million people, 5.3 million were living with HIV as of 2003. South Africa's HIV infection rate is the highest in the world, and it has been rising steadily since 1990. By downplaying the role of antiretroviral drugs, Tshabalala-Msimang is doing HIV-infected South Africans a gross disservice and is posing an obstacle to the efforts to stem the AIDS epidemic in her country.

Sadly for South Africa, officials there have been slow to admit the facts about HIV/AIDS. Although the official government position recognizes that HIV causes AIDS, according to various sources, officials at different times have denied that AIDS is due to HIV or have blamed AIDS on poverty, malnutrition, and even a conspiracy to reduce the population of Africans.

To be sure, poverty and malnutrition are correlated with poor health and susceptibility to disease, including HIV/AIDS. Correlation does not mean causality, however. A virus causes HIV/AIDS. It is true that poverty can force people into situations that put them at greater risk of infection than otherwise. But that virus won't go away just because the infected person is not poor. It is also true that poor nutrition undermines the body's ability to resist opportunistic infections associated with HIV/AIDS and that many illnesses can be effectively avoided by healthful eating. But that virus won't go away just because the infected person is not malnourished.

What's been proven, on the other hand, is that antiretroviral drugs can change the course of an HIV infection from certain death to a chronic but manageable condition. The drugs also have been shown to be effective in preventing the passage of HIV from an infected mother to her unborn child.

In the U.S., for example, the number of people living with HIV/AIDS is growing because of drugs that lengthen the life span of an infected person, according to an analysis by the international AIDS charity AVERT. Furthermore, AVERT says, someone with AIDS who does not undergo antiretroviral therapy "will eventually suffer extreme bad health, followed by death."

Let me be clear: Current anti-HIV drugs are not a cure. They do not kill the virus, but by slowing the ability of HIV to spread in the body, they delay the progression of an infection to full-blown AIDS.

Furthermore, antiretroviral therapy is neither simple nor straightforward. A physician must regularly monitor HIV loads in the patient. The therapy demands unwavering commitment and diligence from the patient. Side effects include nausea, diarrhea, and tiredness. They can be so severe as to limit activity, require hospitalization, and undermine compliance. Drug interactions can complicate the availability of the drug in the body; lower levels in blood could lead to the virus developing resistance, whereas higher levels could be toxic. With time, a therapeutic regime may fail and a different one must be substituted. Much more work needs to be done with antiretroviral drugs to make therapy simpler and more effective.

Cost exacerbates the complications of antiretroviral therapy. According to the Henry J. Kaiser Family Foundation, standard therapy costs between $10,000 and $12,000 per patient per year in the U.S. With ancillary expenses such as visits to doctors, lab tests, and treatment of opportunistic infections, the price tag can be between $18,000 and $20,000.

Even for U.S. patients, such a burden is enormous. For HIV-infected patients in South Africa and other parts of the world, who are mostly poor, it's just impossible. Since 2001, however, governments, international institutions, nongovernmental agencies, and philanthropic organizations have been mobilizing resources to provide antiretroviral drugs to patients in the developing world. Pharmaceutical companies are making the drugs available at low cost in various ways. GlaxoSmithKline, for example, has allowed generic versions of its AIDS drugs to be produced in South Africa. The Indian generics company Cipla will supply drugs at a discount of more than 50%, in conjunction with $10 million pledged by the foundation established by former president Bill Clinton, to deliver antiretroviral treatment to 10 countries (C&EN, April 18, page 12).

This is not to say that there are enough drugs to go around or that drugs alone will solve the global HIV/AIDS crisis. Nevertheless, there is ample recognition of the crisis and its complexity, compassion for patients, and willingness to help from many parts of the world. So, despite enormous missteps in addressing the crisis--including denial by affected governments and a sluggish response from the U.S. and other developed countries, as well as big pharma--progress is now being made. South Africa should focus on tapping into these modest gains.