Recent News: At Front Lines, AIDS War Is Falling Apart

KAMPALA, Uganda — On the grounds of Uganda’s biggest AIDS clinic, Dinavance Kamukama sits under a tree and weeps. Her disease is probably quite advanced: her kidneys are failing and she is so weak she can barely walk. Leaving her young daughter with family, she rode a bus four hours to the hospital where her cousin Allen Bamurekye, born infected, both works and gets the drugs that keep her alive.

But there are no drugs for Ms. Kamukama. As is happening in other clinics in Kampala, all new patients go on a waiting list. A slot opens when a patient dies.“So many people are being supported by America,” Ms. Kamukama, 28, says mournfully. “Can they not help me as well?”The answer increasingly is no. Uganda is the first and most obvious example of how the war on global AIDS is falling apart.

The last decade has been what some doctors call a “golden window” for treatment. Drugs that once cost $12,000 a year fell to less than $100, and the world was willing to pay.In Uganda, where fewer than 10,000 were on drugs a decade ago, nearly 200,000 now are, largely as a result of American generosity. But the golden window is closing.Uganda is the first country where major clinics routinely turn people away, but it will not be the last. In Kenya next door, grants to keep 200,000 on drugs will expire soon. An American-run program in Mozambique has been told to stop opening clinics. There have been drug shortages in Nigeria and Swaziland. Tanzania and Botswana are trimming treatment slots, according to a report by the medical charity Doctors Without Borders.

The collapse was set off by the global recession’s effect on donors, and by a growing sense that more lives would be saved by fighting other, cheaper diseases. Even as the number of people infected by AIDS grows by a million a year, money for treatment has stopped growing.

Other forces made failure almost inevitable.Science has produced no magic bullet — no cure, no vaccine, no widely accepted female condom. Every proposal for controlling the epidemic with current tools — like circumcising every man in the third world, giving a daily prophylactic pill to everyone contemplating sex or testing billions of people and treating all the estimated 33 million who would test positive — is wildly impractical.

And, most devastating of all, old-fashioned prevention has flopped. Too few people, particularly in Africa, are using the “ABC” approach pioneered here in Uganda: abstain, be faithful, use condoms.For every 100 people put on treatment, 250 are newly infected, according to the United Nations’ AIDS-fighting agency, Unaids.That makes prospects for the future grim. Worldwide, even though two million people with the disease die each year, the total keeps growing because nearly three million adults and children become infected.

Even now, the fight is falling short. Of the 33 million people infected, 14 million are immuno-compromised enough to need drugs now, under the latest World Health Organization guidelines. (W.H.O. guidelines are conservative; if all 33 million were Americans, most clinicians would treat them at once.)

Instead, despite a superhuman effort by donors, fewer than four million are on treatment. Just to meet the minimal W.H.O. guidelines, donations would have to treble instead of going flat.Uganda is a microcosm of that: 500,000 need treatment, 200,000 are getting it, but each year, an additional 110,000 are infected.“You cannot mop the floor when the tap is still running on it,” said Dr. David Kihumuro Apuuli, director-general of the Uganda AIDS Commission.

Some battles will still be won. Middle-income countries with limited epidemics, like India, Brazil and Russia, can probably treat all their patients without outside help. China almost certainly can. South Africa might; it has a raging epidemic but is rich by African standards.

But for most of Africa and scattered other countries like Haiti, Guyana and Cambodia, it seems inevitable that the 1990s will return: walking skeletons in the villages, stacks of bodies in morgues, mountains of newly turned earth in cemeteries.

As he tours world capitals seeking donations, Dr. Michel D. Kazatchkine, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, said he had become “hugely frustrated.”“The consistent answer I hear is: ‘We love you, we hear you, we acknowledge the fund’s good results, but our budget is tight, our budget is cut, it’s the economic crisis.’ ”No commander in the global fight openly concedes that the war is over, but all admit to deep pessimism.“I don’t see the cavalry riding to the rescue,” said Dr. Anthony S. Fauci, an AIDS researcher who leads one of the National Institutes of Health.“I’m worried we’ll be in a ‘Kampala situation’ in other countries soon,” said Ambassador Eric Goosby, the Obama administration’s new global AIDS coordinator.

“What I see is making me very scared,” agreed Michel Sidibé, executive director of Unaids. Without a change of heart among donors, Mr. Sidibé said, “the whole hope I’ve had for the last 10 years will disappear.”

Donors give about $10 billion a year, while controlling the epidemic would cost $27 billion a year, he estimated.

His predecessor, Dr. Peter Piot, said he had seen optimism soar and then fade.

Hopes rose from 2001 to 2003 when cheap generic antiretroviral drugs became available, Secretary General Kofi Annan of the United Nations formed the Global Fund and President George W. Bush initiated the President’s Emergency Plan for AIDS Relief, or Pepfar.

“Then, we were at a tipping point in the right direction,” Dr. Piot said. “Now I’m afraid we’re at a tipping point in the wrong direction.” more...

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