By James Rupert
Washington Post Foreign Service
Thursday, September 4, 1997
ABIDJAN, Ivory Coast -- If Francis Koffi happened to live in America, he feels sure, he would be taking one of the new treatments for AIDS, hoping to get well. He would probably still have his job, wife and home.
But like most people here with the AIDS virus, the best Koffi can hope for is to hang on; to live a while longer despite his infection and the poverty and isolation it enforces. He wakes each day in a dingy cinder-block room in the muddy slum where a poor family provides him free shelter. He prays that no illness will enter through his tattered immune system, and that he can scavenge enough money for food.
At 41, Koffi is thin -- 104 pounds -- and burns a nervous energy as one of Ivory Coast's few activists with the virus. For months, he says, he's burned a lot of that energy with a question: "How can I get some of these medicines?"
When the world's giant pharmaceutical firms poured a crop of new AIDS-fighting drugs into the market, they sparked new hope for life and health among hundreds of thousands of people infected with the AIDS virus. In North America, Western Europe and a few other islands of affluence, people with the virus scramble to buy the new drugs for thousands of dollars per month, or get them through government programs or drug trials.
But about 93 percent of people infected with the human immunodeficiency virus (HIV) that causes AIDS live in Africa and other parts of the Third World, where news of the drugs is creating as much despair as hope. Even if they were available here -- and they are not -- a year of treatment would cost more than most Africans make in a decade, or even a lifetime.
"I am as desperate for treatment as anyone else," said Etienne Tape-Bi, another HIV-positive activist in Ivory Coast. "To know that the drugs now exist but that I can't have them because I don't have money, that can make me really feel sick."
The rich nations' excitement over AIDS treatments can engender bitterness among Africans. Jeanne Kouame, who heads an association of HIV-positive people called Illumination-Action, contemplated the American sense of hope glowing from an old Newsweek cover. Above a dramatic photo of new, anti-AIDS pills, a bold headline asked: "The End of AIDS?" In Africa, "we can't even ask this question," Kouame said. "For us, it is not the end of AIDS. We are still at the beginning."
For Africans, virtually all hope in the battle against AIDS is distant and abstract. With years of work, anonymous people of future generations might be spared the disease. "If you have AIDS today in Africa, it's still pretty much a death sentence," said Mark Aguirre, an American physician running Abidjan's only clinic for indigent AIDS patients.
It was in 1978, in the east African nation of Uganda, that a mystery first frightened doctors. Villagers in the forests west of Lake Victoria were wasting away and dying, their bodies' natural defenses against disease mysteriously destroyed. Researchers labeled the phenomenon "acquired immunodeficiency syndrome." Within a few years it had spread worldwide, mainly through sexual contact, to become known and feared by its acronym, AIDS.
Nearly 20 years later, Africa is by far the continent most ravaged. Of the 22.6 million people worldwide whom the United Nations estimates are infected, 14 million, or 62 percent, are Africans. The virus has reached 5.6 percent of all Africans, but only 0.3 percent of people in the wealthy regions: North America, Western Europe and Australia.
Among some populations of those wealthy regions, the percentage of people with AIDS effectively has leveled off, researchers say. That is partly because any epidemic eventually does so, according to local conditions, and partly because people have reacted defensively against the primary causes of HIV transmission in the West -- sexual contact between males and intravenous drug use -- by using condoms or avoiding sexual promiscuity, or using clean needles for drug injection.
The new treatments could provide a powerful new brake on the spread of HIV in the world's wealthy regions "simply because they will make people less infectious," according to Thomas Quinn, a Baltimore-based researcher with the National Institute for Allergy and Infectious Diseases. "But that won't happen in the Third World."
AIDS continues to spread, primarily through heterosexual contact, in Africa and densely populated South and Southeast Asia. The latest annual U.N. summary of global AIDS noted an explosion of the disease in cities of India that "may be spreading rapidly to . . . rural areas through migrant workers and truck drivers, as has happened in many other countries." The epidemic in Asia is likely eventually to be even bigger than that in Africa, Quinn said.
Regional generalizations "lump together vastly different local conditions," and "it's difficult to see more than three years or so into the future," Quinn warned. Still, "if all continues as it is right now, I wouldn't expect to see a leveling off [of new HIV infections] in Africa until the next decade." New infections in Asia would not level off until about the year 2010, he said.
And, researchers have noted, other poor countries are at particular risk for local epidemics, notably those of the former Soviet Union, which for years were physically isolated from AIDS by Soviet travel restrictions.
Amid Africa's agony, Uganda now offers the first signs that prevention campaigns might succeed. Uganda's government has spent years on health education, especially on promoting the use of condoms and discouraging sexual promiscuity, and in the past few years has measured local declines in the rate of new infections. "The message has penetrated the public consciousness," said Agathe Lawson, head of the U.N. AIDS program in Abidjan.
"There are glimmers of hope from East Africa," said Stefan Wiktor, director of an AIDS research project in Abidjan run by the Atlanta-based federal Centers for Disease Control and Prevention. "People have really latched onto them as signs that this eminently preventable disease is finally being prevented."
AIDS in Africa is a powerful illustration of what a recent U.N. study called "the two-way relationship between poverty and illness." Poverty "offers a fertile breeding ground for the epidemic's spread, and infection sets off a cascade of economic and social disintegration and impoverishment," the 1997 Human Development Report said.
AIDS' damage to Africa has been barely visible in the usual macroeconomic statistics, researchers say. Years ago, some economists predicted the virus would shatter the continent's fragile economies by killing off masses of younger people during their most productive years. But Africa also has masses of unemployed who have been available to fill the places of AIDS victims.
Rather, AIDS' damage is visible at the level of families and individuals. Even before AIDS, Africans lived shorter lives with more illness, and had fewer choices about how they worked or lived, than those of any other region. Now AIDS has deepened those measures of poverty.
Many African countries greatly improved health conditions for their people since the 1960s, but AIDS is rolling back the gains. In Zimbabwe, life expectancy was on course to reach 72 years by 2010. Instead, due in great measure to AIDS, it currently is 35 years. Infant mortality, projected to drop to about 35 per thousand births, will be about 115 Zimbabwean children, according to U.S. Census Bureau projections cited by the U.N. report.
And even where African governments aggressively have pushed education about AIDS, fear and ignorance often rule. In Ivory Coast, researchers estimate that 2 million people -- 14 percent of the population -- are HIV positive. But the great majority either are unaware of their infection or keep it a secret, researchers and AIDS activists said.
In Abidjan, the country's two largest organizations of HIV-positive people total no more than 250 members. At a meeting of Illumination-Action, Kouame, Koffi and others said few people will admit openly having the virus. "You are immediately stigmatized, especially in the villages," Koffi said.
Koffi learned he was HIV positive from the personnel director at the luxury hotel where he worked. He had taken a medical test in applying to be a supervisor in the laundry service. "The director called me to his office and told me that I had AIDS and I was fired," Koffi said. His wife left him and he fled briefly to alcohol, he said. Since then, he has searched for work, but "I'm always told there's nothing available."
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.