Help Least Likely Where Most Needed; Africa Ravaged by Virus

Another member, Arsene Tao, took an AIDS test after the death of an army buddy with whom he had shared prostitutes. His parents were stricken with fear. "They would not come close to me. They thought they might catch AIDS by eating from the same dishes as I did," he said. They forced him out of their home and he now lives alone, working for a few hours a day as a street vendor.

Traditionally, African family ties are strong and far reaching, "and always provided a support mechanism for the sick," said Aguirre at his AIDS clinic. "But this [epidemic] has overwhelmed that capacity." From his patients, "I've heard countless stories of people locked away, abused or ostracized from their families," he said.

There are few other sources of help. Like most African countries, Ivory Coast lacks even basic health services for its people, and can do little for those infected with AIDS.

Ivory Coast's prevention campaign -- including radio programs and traveling theater troupes -- "is well organized and financed," said Kouame, who is president of Illumination-Action. But if you are already HIV positive, Kouame said, "you have crossed the line. . . . There is no help."

The country's government-run hospitals and clinics are desperately short of money and materials. "People come in with full-blown AIDS, and can get nothing more than aspirin and a simple antibiotic," or pills to prevent malaria, said Nina Okagbue, a health specialist here with the African Development Bank.

Ivory Coast has only a handful of places, most in the capital, offering care for AIDS. The capital's main hospital offers outpatient care for the equivalent of $ 8.50 a month.

But vast numbers of people are too poor to pay. Research projects run by the CDC or a French foundation offer treatment to a handful. For others, Aguirre's clinic, funded by a U.S.-based charity, Hope Worldwide, is virtually the only place available. But even running at capacity, Aguirre said, it has treated only 2,000 patients in seven years, an invisible percentage of those needing help.

Ivory Coast has won a place in a pilot program being planned by the United Nations to supply limited quantities of the new drugs -- called protease inhibitors -- to four developing countries. The program is designed to try to determine whether there is any practical way to administer the drugs in developing countries. UNAIDS, a U.N. interagency body, will shortly start the program here and in Chile, Vietnam and Uganda, a U.N. source said.

U.N. and Ivory Coast sources agreed that, if the drugs come here, it will be in small amounts, enough to treat only a relatively few people. There will be a fight over who gets this chance to prolong life, the sort of battle here in which an individual's connections to the narrow, powerful Ivorian elite usually are crucial.

"Everybody's desperate," said an HIV-positive woman who works for an AIDS prevention program here. She is one of the few in Ivory Coast who has access to one of the older, considerably less effective anti-AIDS drugs long available in the West -- AZT -- but keeps her treatment a secret. If her HIV-positive friends and co-workers knew of the treatment, "they would insist that I get drugs for them too," which she cannot, she said. "The anger and suspicion would tear everyone apart."

The woman expressed worry over what will happen if the new drugs come this year. As have many, she observed that AIDS has been something of a democratizing phenomenon, placing rich and poor into similar boats, if not exactly the same one. But "the new drugs will create real separation" between elites and ordinary people, she said.

Wiktor, the director of the CDC project here, voiced concern that the drugs "could draw attention and political will away from the campaign for prevention, which has been going pretty well here."

Theoretically, "that could happen," said Isa Coulibaly, the director of Ivory Coast's anti-AIDS program. "But we are going to make sure we keep prevention and treatment coupled," he said. Coulibaly insisted that while the new therapies would be available to only a few, "this will not be a project for the rich. It will be for those who cannot pay."

Despite such altruistic goals, it will be even tougher here than in the industrialized countries to provide significant help to the poor with AIDS. Several specialists underscored the dangers of offering the complicated new therapies in countries that often cannot deliver even the simplest health services.

People who are barely managing to survive are used to cutting corners on everything, including medical care. They are more likely to miss medication or medical tests because they skipped meals, lacked bus fare, or their shantytowns were flooded by rains or bulldozed by police. With AIDS, incomplete or interrupted treatments are dangerous not only for the patient but also for society because they risk letting AIDS viruses mutate into drug-resistant forms.

So vast numbers of Africa's people with AIDS will be excluded from the new therapies, whenever they reach this continent.

But for Africans, dying from an easily treatable disease simply because they haven't got the money is a tragedy and a norm. Each year, according to U.N. figures, 3 million African children die from diarrhea.