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AIDS Obstacles Overwhelm a Small South African Town
By: Rachel L. Swarns
The New York Times, March 29, 2001
Labisa, South Africa — The notice hangs on a drab wall
in a remote clinic here, a symbol of this country's bold aspirations. It
reads, "AIDS treatment available here on request from the
doctor."
Every morning, as the mist swirls over the green hills and roosters
serenade the sun, sickly men and women push through the battered door to
see the miracle worker.
He is Dr. Smangaliso Hlengwa, the only private doctor in this dusty
village and the only physician in this AIDS-ravaged community with anti-
AIDS tablets in his medicine cabinet.
He knows about the plummeting prices of the drugs and the hopes for better
treatment of AIDS patients in Africa. But as the poor squeeze into his
waiting room, his heart sinks. They will leave empty-handed.
Since February, five top drug companies have slashed the prices of their
lifesaving AIDS drugs, bringing them within tantalizing reach of many
Africans for the first time. In March, the tiny nation to the north,
Botswana, announced that, with the help of Western donors, it hoped to
begin providing the medicines to the needy by the end of the year.
That same month, insurance companies in South Africa began to offer
triple-therapy AIDS cocktails to thousands of employees enrolled in their
benefits packages. In April, Doctors Without Borders plans to prescribe
the drugs for free at a public clinic near Cape Town, in what appears to
be the first pilot program of its kind in this country, health officials
say.
But while the price cuts are finally bringing some affordable medicines,
the obstacles ahead for South Africa are plain in Hlabisa, where one of
every three adults carries the deadly virus. Of the 40,000 people believed
to be infected with H.I.V. here, only about 11 can currently afford the
pills that could save their lives, Dr. Hlengwa says.
The cheaper drugs are still too costly for South Africa to provide to the
poor in public hospitals, even though this nation is better off than most
countries in Africa.
Officials say the national health system, which was neglected under
apartheid, still struggles to vaccinate children and track tuberculosis
patients. It would be unprepared to distribute the drugs and monitor
compliance outside of a few big city hospitals, even if the tablets were
free.
South Africa has 4.7 million people infected with H.I.V., more than any
other country, and officials here are confronting a crisis of
unprecedented scale, an epidemic far larger than than that of its
neighbors. Botswana has 50,000 H.I.V.-infected people who need treatment;
South Africa has 600,000 and that number is only expected to rise.
While much will change as a result of the recent price cuts, much will not
unless prices keep falling and donors come forward to help pay for drugs
and health system improvements, doctors and health officials say. Today,
40 percent of the nation's clinics do not even offer H.I.V. tests, a
recent study showed.
"I tell them, `Hang in there. Keep on trying,' " Dr. Hlengwa
said of his patients, who must often choose between buying food, paying
school fees and buying medicine. "I say, `There's good news, the drug
prices are going to be reduced. One day, it will be better.' "
But the words mean little to one 37- year-old patient, a maintenance man,
who only managed to pay for a few months of a more limited (and less
effective) drug regimen, before his money ran out.
The withered man moaned as the doctor rubbed his bony shoulders, listened
to his heart and squeezed the spindly legs that were like brittle twigs.
Dr. Hlengwa told him to stay well until his next visit, even though he
knew there might never be one.
"I still have hope," the doctor said later. He is 29 and went to
medical school with dreams of curing the sick in poor black communities.
It has not worked out that way. "You don't know how many coffins I've
bought," he said.
Of the 25 million people infected with H.I.V. in sub-Saharan Africa at the
end of 2000, 4.8 million are in need of treatment, the United Nations
estimates. Of those 4.8 million, all but 30,000 could expect to die
without the drug cocktails that have to some extent transformed AIDS into
a chronic illness in the West.
In recent weeks, multinational drug companies have begun to slash prices
in Africa, under criticism that the prices they charge in developed
countries deny care to millions of Africans. Cipla, an Indian manufacturer
of generic drugs, cut the price of triple therapy cocktails to African
governments to $600 per patient per year, which was about $400 below the
price offered by the companies that hold the patents. Merck,
Bristol-Myers, Squibb, and, most recently, Abbott Laboratories have cut
prices since then in quick succession.
In South Africa, where the United Nations estimates that 600,000 people
need drug therapy, the price cuts in patented drugs will expand access for
a small but growing number of insured working people. (South Africa cannot
currently import generic copies of AIDS drugs, although it is exploring
sections of its patent law that allow that option.)
Shaun Conway, executive director of the International Association of AIDS
Physicians of Southern Africa, says that if lower prices are made more
widely available to workers with health insurance here, the number of
South Africans with access to antiretroviral therapy could surge from
10,000 to 100,000 by next year.
"It is major, major," said Colleen Pead, a supervisor for Aid
for AIDS, South Africa's largest health plan of its sort. Falling prices
will give nearly 5,000 employees access to an inexpensive version of
triple-drug therapy for the first time. "It's making triple therapy
affordable to working people," she said.
But the government has little hope of extending that access to the masses
in the next few years at least.
To buy the cheapest patented drug combinations, which range from $800 to
$1000 a year, the government would have to spend more than its entire
budget for all medicines, which is about $250 million. This would not
include the cost of laboratory tests or the cost of training doctors and
nurses throughout the public sector, in cities large and small, who have
no experience with the drugs and their side effects.
"I get worried that somebody is going to turn up at our door and say
here are the AIDS drugs, now distribute them," said Dr. Sean Drysdale,
the community health officer responsible for H.I.V. and tuberculosis
programs in Hlabisa. "If we did it, it would be very
piecemeal."
The squat, faded hospital here is so crowded and so short-staffed — 40
percent of its nursing posts are vacant — that workers cannot provide
H.I.V. counseling and testing to all those who need it, he said.
As many as 500 patients, suffering from a variety of ailments, squeeze
into the hospital's 296 beds on some days, their bodies paired like spoons
on narrow mattresses, nurses say. Health workers are so overwhelmed that
they cannot ensure that outpatients with tuberculosis have completed their
six-month drug course.
So how will they possibly monitor AIDS patients who must swallow a
complicated mix of pills every day for the rest of their lives?
"The problems are vastly greater for AIDS patients than for TB and we
can't even manage TB," said Dr. Drysdale, who ran Hlabisa Hospital
until last year. "We only manage to track 60 percent of TB patients.
The rest, we don't know what happens to them. They may have died. They may
still be out there infecting people. We just don't know."
Government officials agree that both prices must come down and the health
system must be upgraded, before the drugs can be safely distributed in the
public hospitals. Many South Africans admire Brazil, which has managed to
provide free generic AIDS drugs to the poor despite a shaky health system.
But officials note that the problem is much smaller in Brazil, where there
are 90,000 people in need of drug therapy.
"I think we're moving in the right direction, but we're not there
yet," said Ayanda Ntsaluba, the director general of the national
Department of Health. "For the first time, we're beginning to think
of antiretrovirals as something within reach."
What is emerging in South Africa, doctors and researchers say, is a
landscape in which geography and class will increasingly determine who
survives. People who have jobs or live near academic hospitals will have
the best chance at getting the lifesaving medicines routinely prescribed
in the developed world.
Meanwhile, the poor in rural Hlabisa will make do with traditional healers
and prayer.
"I heard it, like yesterday, on the radio," said Joyce Celimpilo,
32, who is H.I.V.-positive and lives in a tiny house deep in the tall
grass of the rolling hills. "I heard there is something coming to
South Africa, but they didn't say when or how to get it. Treatment is
there, but here we will all probably die of AIDS."
It is a measure of this country's hunger for a solution that such limited
treatment options are viewed as significant steps forward.
"We are choosing who is going to live and who is not," said Dr.
Eric Goemaere of Doctors Without Borders in South Africa.
In his pilot program, he can afford to offer drug therapy to only 180 of
the 1,500 H.I.V.-infected patients attending a township clinic near Cape
Town.
"Fifty-two percent of South Africa lives in urban areas," he
said. "I say, `Let's start with those people.'
"I don't know how to solve the problem of the rural villages.
Infrastructure is a constraint, a real constraint," he said.
"But those kinds of excuses are good reasons for paralysis. We cannot
afford to wait until the system is fixed. We have to start
somewhere."
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