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photo: DOMINIC NAHR FOR THE WALL STREET JOURNAL
OVERVIEW Efforts to battle AIDS in Africa are at a critical point as U.S. funding for treatment programs begins to taper off Uganda was once a leader in advocating AIDS prevention, but since the introduction of lifesaving drugs, prevention has taken a backseat Health-care providers in the country now face the pressure of an increased patient load as the rate of infection rises
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Desperate Times
By MICHAEL ALLEN Ninsiima Agatha, a 20-year-old mother of two, showed up recently at a medical clinic in Kampala, Uganda—weak, coughing, and desperate to save herself and her two children. She had just discovered that her husband was infected with HIV, and now she had the virus too. If she didn’t get access to lifesaving drugs quickly, she could easily pass the disease to the baby she was nursing. But the staff at the Joint Clinical Research Centre had to tell her the bad news. Even though her husband, a clothes merchant with a girlfriend on the side, was already receiving the so-called AIDS cocktail of drugs elsewhere, there would be none for her. The clinic had enrolled its full quota of patients under its contract with the U.S. government. Ms. Agatha, sprawled on a hospital bed with a toddler and an infant, could barely move. “I feel desperate,” she said. Seven years after the U.S. launched its widely hailed program to fight AIDS in the developing world, the battle is reaching a critical turning point. The growth in U.S. funding, which supports nearly half the world’s AIDS relief, has slowed dramatically. At the same time, the number of people requiring treatment has skyrocketed.
And lately, the global campaign to prevent new infections has suffered some reversals. In Uganda, a lush East African country that once stood out as a shining star in the fight against AIDS, the rate of HIV in the population has begun to tick up again after a long decline. That’s putting an even greater strain on a health system that’s struggling to cope with the hundreds of thousands who already have the disease, and it could be a sign of what’s to come in the rest of Africa. ‘HOW TO LOSE THE FIGHT’ “I personally worry that Uganda showed the way on how best to fight the disease, and now is in danger of showing how to lose the fight,” says David Serwadda, a physician and professor at Makerere University School of Public Health in Kampala and a pioneer in researching the origins of the AIDS epidemic. The most immediate concern is getting enough lifesaving drugs to all those who need them. Under the Bush administration, the President’s Emergency Plan for AIDS Relief, or Pepfar, set aggressive goals for getting people with HIV, the virus that causes AIDS, into drug therapy, eventually enrolling some 2.4 million by the end of last year. The Obama administration, which plans to expand international AIDS treatment to at least 4 million by 2013, nevertheless has signaled nearly flat budgets through fiscal 2011. Critics are questioning whether the reduced spending pace means the administration doesn’t plan to use the full $48 billion authorized by Congress by 2013. “Unless the promised funding is forthcoming soon, we will see an absolute disaster in the next year or so,” says Shepherd Smith, a longtime Christian activist for HIV issues in Africa. “The human tragedy that is nearly upon us is significant and I believe will be a huge disservice to the people of the United States, because we will be unable to keep humanitarian commitments we have made.” Eric Goosby, President Obama’s AIDS czar, says the president is committed to the AIDS fight despite the global economic decline, adding that the U.S. doesn’t intend to turn away anybody who needs treatment: “Our commitment to universal coverage hasn’t wavered.” The challenge is enormous. Some 33.4 million people worldwide have HIV, and under new guidelines by the World Health Organization, the number eligible for treatment has grown to 14 million, dwarfing the 4 million in treatment currently. Another 2.7 million people become infected each year. Those who don’t die first will eventually need to take anti-retroviral drugs, or ARVs, a mixture of medications that helps the body suppress the disease and must be taken every day for life. The therapy, which doesn’t cure AIDS but allows people with HIV to live normal lives, means the number of people who need drugs will continue to grow. One irony is that lifesaving medicine makes the prevention message harder to deliver. That much is clear in Uganda, once a leader in preventing the spread of HIV. LET DOWN THEIR GUARD In the 1980s, long before foreign aid groups arrived on the scene, President Yoweri Museveni grasped the seriousness of the disease. He made it his personal mission to mobilize the country. At the time, there was no known treatment for AIDS. The solution was a homegrown remedy that came to be known by its shorthand, ABC. The only escape, the government said, was to practice abstinence until marriage and to be faithful afterwards—and if all else failed, to use condoms. The prevalence of AIDS eventually fell to around 6% of the adult population, and ABC was soon in use in much of Africa. But over time, Ugandans agree, they let down their guard. Some here say it was only natural for President Museveni to declare “mission accomplished” and move on to other pressing needs. Others say political battles in Washington over how to allocate U.S. aid played a role. But the biggest distraction from prevention was likely the sudden flood of lifesaving drugs beginning in 2005. Fear of HIV dissipated as memories faded about the disease’s effects, and the ABC message lost its punch. “People think that when they get [anti-retrovirals] they get cured of HIV,” says Joseph Lubega, an AIDS activist. The result: New infections have begun to jump again, to around 135,000 per year, and prevalence is believed to be approaching 7%. “We took our eyes off of prevention and focused on treatment and care,” says David Kihumuro Apuuli, director general of the Uganda AIDS Commission. The increased infection rate is putting a heavy burden on health-care providers such as JCRC, one of the top research and care facilities in the country. As one of the early recipients of Pepfar money, JCRC aggressively enrolled people, setting up tents to handle the overflow of patients and seeing over 300 people every day. It routinely turns away new enrollees now. “We made a promise to patients. If they came here for HIV care, we said if you qualify for treatment, you’ll get treatment,” says Fiona Kalinda, clinical manager. “Now we have to tell them to go elsewhere.” DEFYING ORDERS In the case of Ninsiima Agatha, the mother turned away by JCRC, no other clinic would take her on. And the news soon got worse. Peter Mugyenyi, JCRC’s founder, says he just learned that Ms. Agatha’s older child, an 18-month-old girl named Natero Mariam, died on Jan. 7 of AIDS, despite receiving drug treatment funded by the Clinton Foundation. Defying instructions from the U.S. not to add new enrollees, Dr. Mugyenyi says he decided to begin dispensing drugs to the mother so that her two-month- “The cheapest way to save the child is to treat the mother. In the process, the mother’s life will be saved too,” he says. “Without doing this, my conscience would be haunted.” What’s more, clinic doctors have detected disturbing cases of patients already on medication who are sharing their supplies with partners who can’t enroll. In those cases, each patient gets too little medicine. The plan is for the Ugandan government eventually to take greater control over treatment, as more doctors and nurses get trained under U.S.-led programs. But that day is clearly far off. Last year, the U.S. provided $285 million toward Uganda’s HIV/AIDS prevention and treatment efforts, or about 70% of the country’s budget. A BIT OF PORRIDGE In many parts of the country, poverty is the biggest enemy. In the dirt-poor northeast, Amuria district health officer Eumu Silver makes the two-hour trek himself to tend to the people in one village because he can’t find anybody else to take the job. The region has been beset by war, cattle rustlers and now a long drought. Herded into refugee camps, people spread the AIDS virus like wildfire. About 350 are currently on treatment, but the doctor figures as many as 600 are sick enough to qualify. The single testing machine in the nearest big town is constantly on the fritz. At a recent gathering in a village, people with HIV made known their needs. One man just wanted a bit of porridge to take with his medicine, because it’s hard to absorb on an empty stomach. Back in Kampala, Eve Nakitto, a 23-year-old woman with a 5-year-old daughter, had been diagnosed with HIV a month earlier and had sought treatment at Family Hope Centres, a facility run by the U.S.-based Children’s AIDS Fund. The clinic didn’t have any slots available and sent her to find treatment at one of a number of government facilities that theoretically had openings. But after seeking help for a month—including lining up for four straight days at one facility to no avail—she was back. After a pleading phone call, the clinic medical director managed to scrounge a slot. Ms. Nakitto’s eyes welled up, and she spoke of people in her neighborhood who didn’t even bother to get tested now. “They don’t want to know their status,” she said. “Some don’t want to be depressed.”
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