By Craig Timberg
Washington Post Foreign Service
Wednesday, June 20, 2007
JOHANNESBURG -- Amid the morning bustle of Johannesburg Hospital's AIDS clinic, Francois Venter darts from room to room, poking his head inside and asking both doctor and patient, "Are you okay?"
More and more, they are. The clinic he helps oversee is one of the continent's best at distributing antiretroviral drugs. The waiting room fills each day with more than 100 patients whose full faces contradict the stereotype of hollow-cheeked Africans with AIDS.
But beyond the walls of this hospital, Venter says, doctors are not winning -- and probably cannot win -- the war against the epidemic, because it is spreading far more quickly than doctors are treating its victims. Even as billions of dollars are spent expanding access to antiretroviral drugs, the goal of controlling AIDS in Africa remains remote.
"At the moment, I just see a never-ending sea of disaster," said Venter, 37, the dark-haired, long-limbed president of the Southern African HIV Clinicians Society.
Underlying his frustration are grim statistics: For every South African who started taking antiretroviral drugs last year, five others contracted HIV, the same ratio as on the continent as a whole, U.N. reports say. A South African turning 15 today has a nearly 50 percent chance of contracting the virus in his or her lifetime, research shows.
The problem is not the medicine, which is among the most powerful in the world. In places such as the United States and Europe, where prevention programs were already succeeding against much smaller epidemics, the arrival of antiretroviral drugs was a turning point in the battle against AIDS.
But in sub-Saharan Africa, prevention programs have mostly failed to curb the behavior -- especially the habit of maintaining several sexual partners at a time -- that drives the epidemic, research indicates.
So while antiretroviral drugs have prolonged and improved the lives of hundreds of thousands of Africans, millions more are being newly infected with a disease that is still incurable and, for most, terminal.
In South Africa, AIDS deaths are projected to increase at least through 2025 despite steadily improving access to antiretrovirals, according to the Actuarial Society of South Africa. The prognosis on the rest of the continent is at least as bleak.
Global health officials and AIDS activists once predicted that expanding treatment would bolster prevention efforts by encouraging more openness about the disease and making it easier to educate people on how to protect themselves from HIV.
But among African countries with the most serious AIDS epidemics, the only one to report a recent drop in HIV rates is Zimbabwe, which has one of the region's smallest treatment programs.
In neighboring South Africa, attention has shifted from attempting to prevent new infections to treating existing ones, said Suzanne Leclerc-Madlala, an anthropologist at the University of KwaZulu-Natal and a director of one of South Africa's largest AIDS organizations. In meetings, she said, maybe 10 minutes is spent discussing prevention for every hour focused on treatment.
"The whole way of thinking is toward treatment," Leclerc-Madlala said. "But it doesn't solve the problem."A Wave of Optimism
Venter was a doctor in training at Johannesburg Hospital, a vast, hilltop government facility, when he saw a hemophiliac patient receive antiretroviral drugs through a feeding tube as he lay, nearly lifeless, on a bed. A few weeks later, walking unassisted, the man was discharged.
"It was phenomenal," Venter recalled of his first encounter with the medicines that prevent HIV from reproducing. "It was nothing short of a miracle."
The year was 1997, and antiretrovirals were already becoming widely available in wealthy nations. With the drugs, all but the most seriously ill AIDS patients were able to restore their immune systems, control opportunistic infections, regain lost weight and return to work.
But in those early years, the medicine cost thousands of dollars annually for each patient. Faced with millions of infected people, the South African government balked at paying the bill. And President Thabo Mbeki controversially questioned the drugs' safety and effectiveness.
Venter, though, was a believer. Through clinical trials and an informal smuggling ring run by AIDS activists, the hospital was able to keep several hundred patients alive. Some of those also paid for their own pills, often the cheapest, most toxic combinations available.
"I'd say to patients, 'How much can you afford?' " Venter recalled. Based on the answer, he would reply: "This is what I can give you. It's not very good, but it'll buy you a couple months."
That's how Ingrid Moloi -- weighing 86 pounds, with night sweats, tuberculosis and meningitis -- started on antiretroviral drugs in March 2002.
International pressure on pharmaceutical companies had by then begun to bring down the prices of antiretrovirals, but a standard three-drug combination still cost $100 a month, more than double what Moloi earned caring for AIDS orphans for a charity group. A friend paid the bill, allowing Moloi, now 33, to begin a painful recovery that featured severe headaches and sores on her legs.
Five years into what she jokingly calls her "marriage" to the medicine she takes twice each day, Moloi has a round face, swept-back hair and a plump body twice its previous size.
"Really, the results are fantastic," Moloi said on a recent visit to Venter's clinic. "I should have died a long time ago."
Such results spurred a wave of optimism about treatment that eventually swept away political resistance to a mass rollout of antiretrovirals in Africa.
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."