The Cost of Living

This year has marked a shift in the grim headlines on AIDS in Africa. Beyond the catalog of despair, there was a damburst of initiatives from government and industry and a genuine awakening of political will in the West. In one two-month stretch, the drug company Pfizer announced it would give away batches of its costly drug Diflucan to South Africa. Five big pharmaceutical companies signed a declaration of intent with the United Nations to sharply reduce the price of anti-AIDS drugs and the World Bank put AIDS at the top of its development agenda. Last week, German company Bhringer Ingelheim said it would make its new drug for preventing mother- to- child hiv transmission, Viramune, available free for five years to developing countries. American congressman Jim Leach, introducing a bill that would help establish a trust fund to fight AIDS in Africa, called his effort "one of the most important health care initiatives in modern times."

Well, yes. But the real impact of these efforts on the estimated 5 million Africans with full-blown AIDS has been imperceptible so far. Not a single pill packet has been delivered at the promised lower price. Key negotiations with local government officials on drug deliveries have not begun. In the longer term, deep cuts would still leave the drugs too costly for most Africans. Worse, most countries do not yet have the infrastructure to deliver the drugs safely and effectively. Peter Piot, the veteran Belgian AIDS researcher and head of the U.N. AIDS program, likens the recent spate of initiatives to a tide, which is flooding today, mercifully, but could turn at any time. "I hope this will be a turning point in the history of AIDS," he told Time. "The issue is now on the political agenda. But the process is fragile. We have to keep educating the politicians."

The announcement that AIDS drug prices would be slashed was a promise, not a done deal. A senior U.N. official, Julia Cleaves, said she hopes substantive discussions would begin between drug companies and up to a dozen African governments over the next six months. The talks, which will resemble those now under way between Pfizer and the government of South Africa over the Diflucan donation, will focus on how much medicine should be delivered at what cost and in what way. Drug companies will be seeking assurances, among other things, that their products won't be diverted to other markets and resold.

Critics say that this approach gives industry and the profit motive too much clout in an effort that should be aimed solely at curbing a murderous epidemic. Representatives of Medecins sans Frontires, the medical aid and advocacy group, argue the price reduction program will have little impact. They note that even with promised cuts of 85%, AIDS combination therapy will still cost $2,000 a year. (Per capita health spending in the poorest countries is $5.) Giveaways, such as the one announced last week by Bhringer Ingelheim, are short-term solutions, only effective for the duration of the program, they say. msf and other groups are arguing for a stronger emphasis on so-called generic drugs, which some local governments could import, or produce themselves, at a fraction of the cost of brand-name equivalents. One day's dose of a patented version of the drug fluconazole, for example, costs $18 in Kenya and just 30 in Thailand, where a generic version is produced locally. If drug companies were genuinely interested in making a dent in the epidemic, says msf's Daniel Berman, they would slash prices 30-fold, as has been done for some vaccines and contraceptives.

The biggest concern of advocacy groups is that African governments will be so eager to cut a deal with powerful drug companies that they will give up, or fail to exercise, their legal right to import generic drugs. Drug company representatives admit that protecting patents on behalf of shareholders is still their overriding concern, along with restricting the resale of giveaways. But they and officials with the U.N.'s AIDS program argue that motivation is immaterial if even a small amount of additional drugs reach people in need.

Piot says that a bigger problem is the safe and effective delivery of the drugs. Health care infrastructure has collapsed across Africa, and without proper monitoring of doses and combinations, the drugs can be dangerous. Officials also stress that unsupervised use of antiretrovirals the most powerful of the anti-AIDS medicines could trigger widespread resistance, rendering the drugs impotent for millions.

The latest initiatives have at least served to underscore the daunting complexity of Africa's AIDS calamity and how much remains to be done. Of 5 million Africans with AIDS today, 20,000 are receiving some form of therapy. That is less than half of 1%. The rest will die, probably within two to three years, for lack of drugs that Westerners take for granted.