Spread of AIDS in Africa Is Outpacing Treatment

President Bush gave the effort a powerful boost in January 2003 by vowing to spend $15 billion to fight AIDS over the next five years. The South African government announced its own treatment program that August. And that Dec. 1, on World AIDS Day, the United Nations announced a goal of putting 3 million people on antiretroviral drugs by the end of 2005.

Prevention Efforts Lag

With international money flowing in, Johannesburg Hospital slashed the waiting lists at its AIDS clinic, added new patients and hired more staff.

The plastic chairs in its waiting room, which has roughly the capacity and institutional ambience of a small bus station, filled up every morning but were virtually empty by noon because of the availability of doctors and drugs. New patients were typically prescribed antiretrovirals in a couple of weeks. The on-site pharmacy distributed the medicine in less time than it took to have a pizza delivered.

The government did little to publicize treatment programs; three times as many South Africans died last year of complications from the disease as started taking antiretroviral drugs. But a recent episode of the soap opera "Isidingo" featured a woman with AIDS whose boyfriend flew to London in search of a rare new antiretroviral, which on the show was called "V." It saved her life.

The next morning, several patients at the clinic asked their doctors for "V."

Venter assured one of them, a woman in her 30s wearing a yellow tracksuit, that she could get "V" -- actually the relatively new antiretroviral tenofovir -- but cautioned: "You only really need it if you're having side effects. If your treatment's working, your treatment's working."

Yet despite the speed with which antiretrovirals became more available, Venter said he never saw signs that treatment was contributing to a decline in new infections. As the drugs began to work, appetites for both food and sex returned. A startling proportion of the women -- Venter estimated 5 to 10 percent -- became pregnant, which he took as evidence that the clinic's efforts to distribute condoms were not working.

National prevention programs, which have emphasized condom use and HIV testing but rarely featured frank discussions of the dangers of multiple sex partners, have done no better, Venter said. Health officials have also shown little enthusiasm for expanding access to circumcision, despite research showing that it can dramatically slow the pace of new infections.

"South Africa has had huge money poured into it for prevention and done diddly squat," he said.

Moloi had her own frustrations. The roster of orphans whose care she oversaw continued to grow -- it numbers 450 now -- in an indication that AIDS deaths were not slowing. And as orphans reached their mid-teens, Moloi saw them adopting the same sexual behaviors that had led many of their parents to contract HIV.

Boys generally kept several girlfriends, and girls often had two or more boyfriends, she said. They used condoms inconsistently, if at all.

"People are not abstaining. People are not using condoms," Moloi said. "People say it's boring."

She recalled spotting the swollen belly on a petite 16-year-old orphan who only two years earlier had lost her own mother, probably to AIDS. During a visit to the girl's home, Moloi administered a pregnancy test. It was positive. She learned from a neighbor that the girl had two boyfriends.

Moloi urged her to take an HIV test. She refused.

"They are breaking my heart," Moloi said. "I see AIDS. I'm not seeing life."

The Limits of Treatment

Despite the growing availability of antiretroviral drugs, waiting lists in South Africa and other African countries often run into months. Because of heavy stigma, many of those with AIDS die without acknowledging they have the disease. And others living beyond the reach of the best health facilities struggle to find doctors who have access to antiretrovirals.

The international aid group Doctors Without Borders reported last month that severe shortages of doctors and nurses threaten to stall the rollout of AIDS treatment programs in southern Africa, home to the world's most severe epidemics.

Keeping patients on the medicine, which generally must be taken twice a day for the rest of their lives, has proved more daunting than health officials once predicted.

The World Health Organization reported in April that 1.3 million Africans were taking antiretrovirals, an increase from 100,000 just three years earlier. But most programs lack the ability to track how many of their patients continue taking the medicine.

Boston University epidemiologist Christopher J. Gill studied African treatment programs that did monitor the outcomes of all of their patients, a group that encompassed 66,753 people in 13 countries. Gill found that 40 percent of the patients could not be accounted for after two years, meaning that they had stopped taking their medicine, transferred to another program or died.

Johannesburg Hospital, with resources unimaginable in most of the continent, is doing much better.

Yet Venter has come to regard using antiretrovirals to fight an AIDS epidemic as akin to using chemotherapy and surgery to fight lung cancer. It would cost less, and save many more lives, to find some way to curb smoking.

At best, he estimates, South Africa's medical system might find a way to reach about half of those who need antiretrovirals, instead of the 20 percent receiving them now.

"On the public health level, it's not going to make much of a difference," he said. "I don't think we're going to treat ourselves out of this epidemic. . . . No way."