Battling the AIDS Epidemic

SUSAN DENTZER: This year's international AIDS conference in Durban, South Africa is the 13th global session on the disease. It's also the first to be held in Africa. That alone is significant, since it's believed that the HIV virus that causes AIDS first originated in Africa decades ago, and the continent is also where the disease has wreaked far and away the greatest human devastation.

PETER PIOT: The lifetime risk of dying from AIDS is become really, incredibly high in several countries. It can be high as 50 percent in countries like South Africa, Botswana and Zimbabwe.

SUSAN DENTZER: In fact, it's estimated that of the 34 million around the world who are infected with HIV, Nearly 25 million are in Africa. That's equivalent to the number of Europeans killed by the bubonic plague in the 14th century. In South Africa alone, nearly one in four adults are infected and a total of more than four million adults and children. And a new UNICEF report notes that in countries like South Africa, Lesotho and Zimbabwe, one in four young women, ages 15 to 24 are infected with HIV, as are one in ten young men.

SANDY THURMAN: This epidemic in South Africa and around the world is out of control. The numbers are staggering, and we all ought to be mobilizing to do more, and that means in the United States and other donor nations as well.

SUSAN DENTZER: Amid that dawning reality, there were widespread hopes this week that South African President Thabo Mbeki would back off earlier statements; those seemed to call into question whether HIV causes AIDS in Africa, but that didn't happen. Instead, in an opening address to the conference, he singled out poverty as the chief cause of AIDS.

PRESIDENT THABO MBEKI: It seemed to me that we could not blame everything on a single virus. It seemed to me also that every living African, whether in good or ill health, is prey to many enemies of health that would interact one upon the other in many ways within one human body.

SUSAN DENTZER: As global AIDS experts worried that Mbeki's comments would slow efforts to attack the disease in South Africa, researchers at the conference unveiled several hopeful studies. One showed that treating pregnant African women with the drug AZT significantly reduced the risk that they would transmit the virus to their babies. However, if those women went on to breast feed their infants, the risks of transmission rebounded. Researchers said that makes it more urgent than ever to find acceptable alternatives to breast feeding among infected African women. Another study unveiled at the conference showed unexpectedly good results from treating small groups of HIV-infected Africans with combination drug therapies; those are widely used in the U.S. and other developed countries. That's likely to increase pressure on international drug companies to slash prices on these drugs or give them away for free, as some have already done. One is Glaxo-Wellcome, which produces AZT.

PETER MOORE: Glaxo-Wellcome has been speaking to the South African government for the last three-and-a-half years, whereby we've been putting preferential prices on the table, and when I'm talking preferential prices, I'm talking prices of our anti-AIDS drugs to reduce the costs by between 75% and 80% of the world average prices.

SUSAN DENTZER: Apart from the staggering costs of drugs, world health leaders say huge sums of money are needed now just for basic AIDS prevention and care in Africa and other developing nations.

PETER PIOT: What we know, facing us, a major challenge is that to mobilize new resources, they are highly inadequate. We estimate that Africa alone needs between $1.6 billion and $2.6 billion per year to contain this epidemic.

SUSAN DENTZER: The Durban conference is scheduled to run until Friday.

JIM LEHRER: Margaret Warner takes it from there.

MARGARET WARNER: Why is the AIDS epidemic in Africa so much worse than elsewhere? And how can infection rates on the continent be brought under control? To explore these issues, we turn to two experts in the field, who join us from the international AIDS conference in Durban, South Africa. Dr. Malegapuru William Makgoba is president of the South Africa Medical Research Council, that country's leading medical research institution. And Jon Cohen is a correspondent for Science magazine, who has covered the AIDS epidemic for a decade. He's the author of an upcoming book called Shots in the Dark: The Wayward Search for an AIDS Vaccine. Welcome, gentlemen. Dr. Makgoba, starting with you, why are the rates of infection in Africa, in sub-Saharan Africa so much greater, so much worse than they are in virtually any other part of the world?

MALEGAPURU WILLIAM MAKGOBA: Well, the reason why the rates are so high is that we have a high rate of migrant labor in sub-Saharan Africa. We have a high prevalence of sexually transmitted disease in sub-Saharan Africa, and we seem to have acquired, I think, multiple strains that are all sort of bubbling as separate epidemics that coalesce, I think, in sub-Saharan Africa. I think in addition to this, I think you have a great sense of denial. AIDS and HIV are silent diseases. You have a patriarchal society, and a society really that is in denial about an epidemic that is ravaging, within the context of poverty, and you have a thriving commercial sex work industry, and to a certain extent, a growing, I think, drug trafficking industry that is occurring, I think, within sub- Saharan Africa.

MARGARET WARNER: Jon Cohen, what would you add to that?

JON COHEN: Well, there's some new research that suggests that strains that circulate here might be somehow different from the strains that are circulating elsewhere. It's still preliminary, but there might be some difference there. The other thing is, many countries in sub-Saharan Africa have had war. All of these things are things the virus loves, and takes advantage of.

MARGARET WARNER: Jon Cohen, staying with you for a minute, there's also a big disparity within the African continent, though, with the six or seven countries of Southern Africa having much higher rates than in Central Africa, for the most part, having higher rates than in West Africa. Is there any research, or any understanding of why that is?

JON COHEN: I think there's a lot of effort to try to understand it, but I think right now, people are very baffled by it. Sub-Saharan Africa is really many different places, and in Southern Africa, there really wasn't very much HIV here at all until the early 1990s. It wasn't here, and it was in places like Uganda, it already was in places like Cote D'Ivoire on the West Coast -- in the north. And it's really been a shock to southern Africa that it's exploded here the way that it has.

MARGARET WARNER: So, would you agree with Dr. Makgoba when he talked about denial?

JON COHEN: Yeah, absolutely. I spent most of march traveling to six different countries, and I was in Gulu, Uganda, which is in the north, in a TB ward where 50 percent of the people were infected, and I was speaking to a man one day and asked him whether he knew anyone who was infected in this tuberculosis ward. And he said he had never met anyone who had had AIDS.

MARGARET WARNER: Dr. Makgoba, give us your sense of... first of all, do you agree with the common view that Africa is having a much harder time on the prevention and treatment end, as well as on the causes end -- the prevention and treatment, and, if so, why is that?

MALEGAPURU WILLIAM MAKGOBA: Well, I think most countries in sub-Saharan Africa are really poor, and cannot, I think, afford you know, the exorbitant prices for anti-retrovirals that are easily affordable within the West. But also, I think there has been a tendency to have a vacillating type of leadership, because there is so much, I think, denial. I mean, you just have to move into Zimbabwe where, you know, the president of the country is still denying that there are issues such as homosexuality that are being practiced within that country, so I think it is the combination of silence, of denial, of vacillating leadership, and sometimes of sending confused and mixed signals that create, I think, the impediment for prevention, I think, in most of sub-Saharan Africa.

MARGARET WARNER: Dr. Makgoba, staying with you, explain to a western audience a little more about this denial phenomenon, because in almost every country, it's a squeamish subject to discuss. What do you really mean by denial? Do you think it's stronger in sub-Saharan Africa, and why?

MALEGAPURU WILLIAM MAKGOBA: Well, basically, I think you can go around, say, in a country like South Africa. You can do HIV tests, you can see someone with the clinical symptoms and signs of HIV/AIDS, and nobody would be confident, I think, to tell the person they are HIV -- they are suffering from AIDS, let alone, I think, people coming out in public to say that actually, they are HIV positive. I think in South Africa today, there has only been one president I think it's Justice Edward Cameron, who has publicly, I think, announced that he is HIV positive. And you are talking about a country that has got about 40 million people, and 4.2 million people that have been documented to be either living with AIDS or HIV positive. And you have just a few handfuls of people who can actually come out publicly and say that they are living with HIV, or they have got HIV/AIDS. That is the level of denial that is existing, and you can go to funerals almost every weekend, and you would know that the person who is dead has all the typical features of HIV/AIDS, but they will try and find another simply reasonable explanation as to the cause of death, and this occurs, I think, with such consistency and repetition that you simply, I think, stop listening to what the cause of death is. And that, as I say, is the level of denial that is going on within Southern Africa, and in South Africa in particular.

MARGARET WARNER: Jon Cohen, turning to the conference, what have you all heard from researchers and so on in the last couple of days that look promising, in terms of helping address this problem in Africa, in particular?

JON COHEN: Well, it's been a remarkable conference, because there's been an attention toward providing drugs to poor people that has never existed before. It's really just in the last few weeks that you've seen this incredible outpouring from governments, from pharmaceutical companies, from non-governmental operation, UN aid. And people realize that it's just no longer business as usual; that you can no longer separate rich and poor countries, and pretend as though poor countries can't have access to drugs. Drug companies have been coming out of the woodwork. One company is offering free drugs to all pregnant, infected women in poor countries for the next five years. I think that's unprecedented in the history of medicine.

MARGARET WARNER: And what do you think has brought this about?

JON COHEN: One thing is simply that drugs are working in wealthy countries, and the most dramatic advance that AIDS research has had in the entire course of the epidemic is the ability to lower the rate of transmission from an infected mother to a child. A great deal of effort was put into figuring out ways to cheaply and simply deliver pregnant, infected women in poor countries. Many studies have gone on in several African countries to do this, and as remarkable and dramatic as it seems, they work. And so people want these things now, and the drug companies are being pressured to deliver these things, especially when it only costs $4, especially when the drug company says, "It's free." So that's been one arm of the impetus, and the other is just seeing the level of devastation that's occurring here. There's compassion. The world is recognizing, I think, just how incredibly devastating this is. It's when you walk into places and see hundreds of people dying, it hurts your heart; it has to.

MARGARET WARNER: Dr. Makgoba, do you think the big American and European drug companies are stepping up to the issue of cost and access to drugs in the way that they need to, in your view?

MALEGAPURU WILLIAM MAKGOBA: Well, I think they are trying their best, but I think what needs to be understood, I think, in the context of Africa, is the fact that it seems like, as much as they are offering all this tremendous price reduction, they seem to go first, I think, to the media rather than actually discuss with an African government. And I think that sort of disrespect is actually very infuriating, I think, to Africans. I think African leaders or African politicians do like, I think, to operate in an environment that shows that I think they are participating as equal partners, rather than in situations where they feel that they are being driven by the media and the public outcry. And unfortunately, the drug or the big pharmaceuticals don't seem to have appreciated that as I've often said, you don't criticize, I think, African leaders in public. You talk to them first, and you understand the dynamics of that interaction, and I think you can jointly make a public statement rather than, you know, the director or the president of a drug company going to the media and calling a press conference, and saying that, "I've made this reduction," without, I think, the proper consultation.

MARGARET WARNER: But...

MALEGAPURU WILLIAM MAKGOBA: Africans take this very seriously and sometimes they feel hurt, and they feel that they need that.

MARGARET WARNER: Jon Cohen, but pragmatically, does the infrastructure exist in Africa? There have been questions about, even if the drugs are provided, it would greatly reduce cost, or for free, that many of these countries lack the medical infrastructure to deliver them, administer, follow up, all of that? What's your view on that?

JON COHEN: Clearly, in lots of places, infrastructure is an incredible problem -- maybe in most places. But as one researcher said to me, Africa is not one village. It's many different places. Even South Africa is many different places, and you can't speak of Africa as one place. Some places, Durban for example, you can see, "next exit, three miles" on the freeway. It's a very developed place. We're sitting in a hotel space right here. You wouldn't know where you were if I didn't say you were in Durban. It doesn't look like an impoverished place. And it has a terrific infrastructure. But if you go two hours North of here, you'll see mud huts, and the water supply won't be very good. So, you really have to take it on a case-by-case basis, and yes, ultimately infrastructure is a crippling thing for much of Africa. It is a problem. But for many parts of Africa, it isn't, and I think the drive right now is to understand what a complicated continent Africa really is.

MARGARET WARNER: All right, well Dr. Makgoba and Jon Cohen, thank you both very much.