By Albert Samaha
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Even collectively, these initiatives do not come close to providing worldwide access to care. The United Nations AIDS program, UNAIDS, estimates that Africa alone requires $3 billion a year just to conduct prevention programs and provide basic care, such as antibiotics. On the eve of the conference, UNAIDS director Peter Piot said that less than a tenth of that amount"peanuts"was actually being spent.
What's more, any new commitment will have to last for the long haul, because "we are still not at the midpoint of this epidemic," researcher Roy Anderson declared in a major scientific address. In contrast to viruses such as influenza, which spreads rapidly through populations, HIV spreads slowly. So, Anderson said, the pandemic "must be measured in decades."
As the virus spreads, it also mutates and evolves. Through a process called recombination, different strains of HIV, called subtypes, can shuffle their genes to form new, hybrid strains. Francine McCutchan, an expert on HIV's diversity, revealed that a new variant has been found that mixes five separate subtypes of HIV. This mosaic virus was first found in Senegal, but it has also infected an American soldier who apparently contracted it in Germanyproof, said McCutchan, of "how foreign travel can bring in new strains and expand the repertoire" of HIV.
Still, by the end of the conference, an energized Piot declared that Durban had marked "a turning point" largely because of the spirit of the participants and the flurry of new initiatives. Two of those initiativesone aimed at driving down the price of medicine, the other a grassroots effort designed to keep AIDS activists alive and fightingepitomize the actions taken at the conference. They also reveal the daunting task of bringing treatment to the third world.
Brazil has been the pioneer. Pushed by a robust activist movement and fortunate to have less than 1 percent of adults infected with HIV, Brazil has committed to providing anti-AIDS drugs, called anti-retrovirals, for all who need them. In practice, many of the country's HIV-infected people do not get the drugs, but nevertheless, Brazil's HIV death rate has been cut in half since the program began four years ago, and hospital admissions for AIDS patients have fallen by 80 percent.
What happened to the price of the drugs is equally striking. Even though Brazil is wealthy compared to many sub-Saharan nations, the cost of the medications was nearly back-breaking. So Brazil started making generic versions of several HIV drugs in its own government laboratories. For those drugs with no competition from government-produced generics, the price over the last four years edged down by less than 10 percent. But for drugs that the government makes, the price tumbled by more than 70 percent.
Competition appears to get better results than negotiation. For example, UNAIDS bargained with the major pharmaceutical companies and received special discount prices for a pilot program in Uganda. But Brazil's generics cost less. For example, one day's supply of the anti-HIV drug stavudine, made by Bristol-Myers Squibb, costs $6.20 in Uganda, almost three dollars off the U.S. price. But in Brazil, where the drug is made by the government, the same dose costs just 56 cents. No wonder Ugandan doctor Peter Mugyenyi, whose clinic is the main site for the UNAIDS program, is fed up with what he calls "this nice-boy negotiating."
Paulo Teixeira, director of Brazil's national AIDS program, came to Durban bearing a message from his government. "We are not able to be the drug supplier for Africa," Teixeira explained, but Brazil has offered to share everything it has learned, from negotiating for lower prices to setting up pharmaceutical assembly lines. "We're keen on this partnership," says Ntsaluba, the South African director general of health, adding that a team from his country will be heading to Brazil "very soon."
South Africa cannot adopt Brazil's model tomorrow. For one thing, it has about eight times as many people with HIV4.2 millionwhich would require drug manufacturing on an enormous scale. For another, Brazil was able to make generics legally because it had not yet entered into a World Trade Organization agreement that restricts making knockoffs of patented goods. "It might seem heroic to produce generic drugs," says South Africa's Ntsaluba, "but if the rest of the world put us on trade sanctions, then everyone in South Africa would suffer."
But both South Africa and Brazil, which recently signed the WTO agreement, are considering exploiting a loophole that allows for generic production in the case of national emergencies. Teixeira says his government is currently negotiating the price of two drugs and will go ahead and produce them "if we don't get good terms on the original products." This is the real power of generic manufacturing: It is the trump card in what Teixeira calls "an international movement to push the price of medicine down." Already, India and Thailand manufacture generic AIDS drugs.
That threat, as well as the sheer humanitarian urgency, is pressing drug companies toward "differential pricing"charging high amounts in the first world in order to recoup the research and development costs, while charging low prices in developing nations. Carl-Heinz Pommer, an executive with Boehringher Ingelheim, told the Voice, "There is a real feeling that differential pricing is the way to go." The strongest move in that direction has come from Glaxo Wellcome, which has offered to chop off 80 percent of the American price for one of the mainstays of AIDS treatment, a pill called Combivir.