Treatment Action Campaign News, 09 August 2000. ------------------------ TAC news is divided into 2 sections, an "In Brief" section, which contains headlines and "BRIEF" descriptions of events, and an "In Depth" section which contains full versions of some of the events mentioned in the "In Brief" section. Regards, Nathan Geffen on behalf of the Treatment Action Campaign http://www.tac.org.za mailto:info@tac.org.za In Brief -------- * Transcript of Judge Cameron's speech at the TAC-MSF Treatment Access Conference. This really should be read. (see In Depth section) * BRIEF: Attendants to Christopher Moraka's funeral spontaneously marched through the streets of Nyanga in Cape Town demanding access to HIV treatments on Saturday. * BRIEF: The Ministry of Health is meeting this weekend to discuss mother-to-child-transmission prevention (MTCTP). TAC sent the minister of health a letter, yesterday, outlining what the essential elements of a successful MTCTP program. We will publish the letter shortly. * Constitutional Court hearing on pre-employment testing takes place on Friday. (see In Depth section) * Clem Santer calls for access to treatment. For overseas subscribers who have not heard of him, Santer is an influential spokesperson for and to South African business. (see In Depth section) * Invitation to a Seminar Topic: HIV and the Health Worker: Ethical, Human Rights and Legal Issues Date: Tuesday 15th August 2000 Venue: Conference Rooms 1/2, Barnard Fuller Building UCT Health Sciences Faculty, Anzio Rd, Observatory Time: 4 - 5.15 pm (see In Depth Section for further details) * An article by Pullitzer prize winning journalist, Mark Schoofs "How African Science Has Demonstrated That HIV Causes AIDS" (see In Depth section) * Here is a link to the WHO blue book (well worth reading) http://whqlibdoc.who.int/hq/1998/WHO_DAP_98.9_Revised.pdf * CIPLA prices for Nevirapine (courtesy of Jamie Love of CPT) (See In Depth section) * The TAC website, www.tac.org.za is being given a new look. Details to follow. Apologies for the delay in updating it. * FUNDRAISING: We are selling the following items to raise money for our campaign to import generic medication into the country, as well as other TAC campaigns: 1. HIV Positive T-Shirts USD$10 2. TAC Video USD$20 3. Beat-it Video USD$50 All prices exclude postage. Please email info@tac.org.za to place an order. T-shirts will only be sent when we have received orders for over 100. We cannot begin printing them before then. Receipts will be supplied for all goods purchased. Payment details will be supplied via email. Next week: TAC's legal action against Pfizer TAC's correspondence with the Minister of Health ----------------------------------------------------------------- In Depth -------- 13th INTERNATIONAL AIDS CONFERENCE DURBAN: 9-14 JULY 2000 MSF/TAC Satellite Conference IMPROVED ACCESS TO HIV/AIDS DRUGS IN DEVELOPING COUNTRIES Closing Remarks by Edwin Cameron Sanibonani! Ninjani? Nami ngiyaphila. Ladies and gentlemen, I have greeted you all in the language of my Zulu-speaking compatriots. I told them that I saw them. Their response was initially passive: they acknowledged my statement. Then I asked them how they were. They told me that they are well and living. I was able to reply the same. That to me was significant. It wasn't merely a formality. It was an important part of my reality here today. I'm here, I'm able to be talking to you, I'm able to engage with you, I'm able to speak with you about this important topic, because I am on anti-retroviral treatment. Three years ago in October 1997 I fell very ill. Is there anyone here today who's feeling ill? Yes, I see you. Is there anyone who's feeling ill from AIDS? Who wants to speak about it? Well I can tell you that you taste death in your mouth when you have AIDS. Your body stops absorbing food. Your body stops producing energy for you to work and think and to enjoy life. Your body starts breaking down against its own will, and you feel terrible. When I fell ill I had good medical care. I had a good doctor. He gave me medicines to deal with the things that were making me so ill. And then he gave me the medicines that treated the underlying cause, which was this virus that was stopping my body's ability to defend itself against the things that were making me ill. That was nearly three years ago. The average survival time for someone like me — a well-cared for, medically attended, well nourished male in his mid-40's — after the onset of full blown AIDS is 30-36 months. I fell ill 33 months ago. So I should be dead by now. Instead of which, I'm here, "ngikhona", "ngiyaphila", I'm still living. I'm still living, when there are people here on the street outside, people in Kwa Mashu, in Dundee, in Nongoma, on the South Coast, who are feeling terribly ill, who are dying. There are people throughout Africa, 24 or 25 million people in Africa and nearly 34 million people in our whole world who are this moment dying. And they dying because they don't have the privilege that I have, of purchasing my health and life. I'm a judge. I have many privileges and benefits as a judge. I do exercise them. I don't claim not to. I have the privilege of a secure position. I can't be sacked by an employer that discriminates against me, because the Constitution says I can't be sacked, except for very rare conditions. I also have loving family who here today. And I have colleagues and friends who support me. And most importantly, on the salary of a judge I have the privilege to purchase my life. I can afford my medication it costs me $400 every month, R2550 a month. Who here is working? Who earns R2550 a month? How many of you are not working at all? Too many, too, too many people are not even working. Now why should I have the privilege of purchasing my life and health when 34 million people in the resource poor world are falling ill, feeling sick to death, and are dying? That to me ladies and gentlemen seems a moral inequity of such fundamental proportions that no one can look at it and fail to be spurred to be thought and action about it. That is something which we in Africa cannot accept. It is something that the developed world also cannot accept. A century ago in the trenches of the first World War, 18 million white Europeans died because of corporate greed, governmental ineptitude, and human folly. In Africa we face death and dying and misery and loss and mourning on the same scale. Except that this does not have to happen. Our history teachers us South Africans. I'm proud to be a South African and I'm proud to be an African. I'm white and I'm an African and I'm proud of that and our history has taught us a great deal. Our history has taught us that we don't have to accept "inevitabilities". We don't have to accept what one leading lady from the United States in the seminar I attended yesterday called "a sad reality", that these medications are not accessible to Africa and the resource-poor world. We don't accept "sad realities" in South Africa. If we accepted what others told us were sad realities, we would still have had a racist oligarchy oppressing our people. We would have had indescribable chaos and bloodshed. We have shown through our history that we will confront those "sad realities", and we will change them. Our country is not perfect. But we have a democracy anda Constitution and national aspirations that we can be proud of. You are here today because you want to be proud of our country in every respect. You want us to be proud of the way that we can make health and life available to everyone. At the seminar where I was yesterday and this morning, Dr William Makgoba who came to speak to you earlier this morning, released figures. These figures come from our own Department of Home Affairs. He gave them to the Sunday Times, and they are published today. They show that the natural order of things — which is that people die late and women die after men — has been reversed in our country. It has been reversed particularly in Kwa-Zulu Natal. Women are dying in their early 20's and mid- 30's. And women are dying before men. These are figures that show that something dramatically and terribly wrong is happening to our people. And what is it? We know what it is. It's not TB. It's not malaria. And it's not malnutrition. It is a virus. It's a virus called HIV. It causes AIDS. And if AIDS is not treated, it leads to terrible sickness and death. But there is a greater fact even than that. The greater fact is that those medications as you now know after this morning's discussions are available. They exist and can be cheaply produced, but the drug companies are keeping them unaffordable and inaccessible to the people who most urgently need them. We need to change the facts of our world. We need to change the facts that are going to lead to the deaths of 25 million people in Africa. And we do plan to change them. That is our role as Africans, as proud Africans, as proud South Africans. We will confront that fact and we will change it by changing the conditions that create it, through principled political action, through legal action, through principled commitment to what is right. We will challenge the future by intervening in the present. Thank you, very much. ------------------------- Constitutional Court Hearing on Pre-employment HIV Testing On Friday August 18th at 10,00am the Constitutional Court will hear an appeal against a High Court judgment (Hoffman v SAA) that found South African Airway’s policy of mandatory HIV testing of applicants for cabin crew and their refusal to employ people with HIV in this position to be fair. The AIDS Law Project (ALP) has been permitted by the Court to act as an amicus (friend of the Court) and expert evidence collected by the ALP in another matter against SAA (“A” v SAA) will also be considered by the Court. “A” vs SAA led to a settlement where – in almost exactly the same circumstances -- SAA admitted to the Labour Court that their disqualification of “A” from employment solely because he had tested HIV positive was “unjustifiable”. This is the first Constitutional Court hearing on a matter related to unfair discrimination against people living with HIV/AIDS. Although it relates to employment practice, the judgment is likely to have far-reaching implications in relation to all areas of life where unfair discrimination takes place on the grounds of a person’s HIV status. Hearings of the Constitutional Court are open to the public. We encourage trade unions, people living with HIV, treatment activists and all those committed to equality and dignity to attend. ------------------------- CLEM SANTER CALLS FOR ACCESS TO TREATMENT Healthy with HIV cheaper than ill with AIDS’ Judith Soal Cape Times – 19 July 2000 Employers who say they can’t afford to treat HIV-positive staff members should count the costs of not treating them, said business analyst Clem Sunter on Tuesday. "Just do your sums," Sunter told a sceptical questioner at the Cape Times Nashua Breakfast Club. "You’ll find it costs a lot less to keep people alive and well than to allow them to become ill and die." The biggest expense, he said, was the increase in sick leave. "Studies have shown that all the other costs – funerals, medical aids, recruiting and training new staff – fade in comparison to the costs of absenteeism," he said. Antiretroviral therapy has led toa dramatic drop in Aids-related deaths in developing countries, allowing people who had been forced to retire to return to healthy and productive lives. At current prices, treatment with two of these drugs – dual therapy – costs about R25 000 a year, with the recommended triple therapies costing up to R50 000. The Nobel prise-winning group Medicins Sans Frontieres believes good quality generic medication could bring the cost down to $200 (about R1 392) a year in developing countries. Sunter said if large companies like Anglo American were to pressurise pharmaceutical companies to reduce their prices "there is no doubt the drug companies (would be) willing to negotiate". He supported calls by Aids activists for the government to manufacture or import generic versions of the drugs. "Any avenue that can bring down the price of treatment must be explored," he said. "This will benefit everyone, not just those with medical aids. The private sector also needs to enter partnerships with the public health services to see how we can assist to get the necessary medication to everyone living with the virus." The first step for businesses, he said, was to offer voluntary counselling and testing to all employees. "You can’t test anyone for HIV against their will, but you can provide the option of testing and treatment," he said. "Once people are tested there is something you can do. If they are positive they can be put on a wellness programme that includes good nutrition and a healthy lifestyle. Those negative will be helped to stay that way." Sunter, who teamed up with Natal University professor Alan Whiteside to write AIDS: The Challenge for South Africa, said providing treatment to HIV-positive mothers was a crucial component of any Aids prevention strategy. "It’s a no-brainer. Simple, cheap treatment can halve the number of children being born with HIV. We need to implement these programmes as soon as possible." More controversial was the question of whether the state should provide antiretroviral drugs to sex workers as a priority group. ------------------------- Invitation to a Seminar: HIV and the Health Worker: Ethical, Human Rights and Legal Issues As the expanding HIV epidemic increases the numbers of HIV-infected patients presenting to our health facilities, the human rights, ethical and legal issues surrounding the practice of health care in relation to HIV infection are becoming increasingly challenging. * When is it justified to test a patient for HIV? * How can one inform a partner of a patient's HIV status? * What preventive policies are justified from a human rights, legal and ethical perspective? * How can we balance conflicting rights? * What are the legal constraints health workers face? * How do ensure that public health policies are compatible with legal and human rights considerations when combating the epidemic? You are invited to an open seminar on this issue to be hosted by the Department of Public Health. The speaker will be Mr Mark Haywood, Director of the AIDS Law Project from the Centre for Applied Legal Studies (CALS) at the University of the Witwatersrand. Mr Haywood has extensive experience of legal advocacy on behalf of people with HIV and has been centrally involved in lobbying and campaign work around increasing access of HIV-infected people to treatment and care. He will speak briefly to the legal and human rights issues relating to professional practice, and health care policy, drawing on the experience of the ALP in fighting for fair treatment of those with HIV, whereafter the seminar will take the format of a general discussion. The aim of the seminar is to clarify common dilemmas that arise in relation to HIV so that legal, human rights and ethical issues can be integrated in our clinical and public health practice. Date: Tuesday 15th August 2000 Venue: Conference Rooms 1/2, Barnard Fuller Building UCT Health Sciences Faculty, Anzio Rd, Observatory Time: 4 - 5.15 pm ------------------------- How African Science Has Demonstrated That HIV Causes AIDS by Mark Schoofs BITOKE BISALILE, UGANDA—It had to be witchcraft. For more than a year, Matia Katongole just kept getting thinner. His stepmother remembers his feet: As the bones showed through ever more sharply, they seemed to elongate. Matia's family decided, with rising terror, that the hex had come from Tan-zania. Matia was a trader in beans, rope, pots, and anything else he thought might turn a profit, and he conducted much of his business with Tanzanians across the nearby border. Matia had once bought some goods on credit but failed to fully pay back the loan. Now, he was too weak to make amends and lift the curse, so his father sent one of Matia's busi-ness partners back across the border with a goat, copious quantities of local banana wine, and 80,000 shillings—far more than the original goods had been worth. It didn't work. Less than a month later, Matia's father was holding his son, trying to give him a little tea. "Matia vomited," his father recalls, "and died in my lap." That was 1980, before villagers here in Uganda's Rakai District had seen enough patients like Matia to coin their own term for the new disease, Slim, and before enough trickled into clinics for medical authorities to suspect that they had an epidemic on their hands. Not until five years after Matia's death was Slim proven to be AIDS. This week, after an estimated 14 million Africans have followed Matia's fate, the first World AIDS Conference ever held on African soil opens, bringing about 10,000 doctors, researchers, and activists to Durban, South Africa. Past World AIDS Conferences have often slighted the contributions of African science. At the last one, held two years ago in Geneva, the editor of the British medical journal The Lancet noted that whenever third-world speakers rose to present their findings, "seats emptied and the hall began to bleed delegates." But this conference, chaired by South African doctors, offers a chance to showcase research conducted on the continent where HIV almost certainly originated and where the epidemic is far worse than anywhere else. But earlier this year, African science got snubbed by a most unlikely source: South African president Thabo Mbeki. Apparently after surfing the Web, Mbeki resurrected the notions of a small group of self-styled "AIDS dissidents," the most prominent of whom is University of California virologist Peter Duesberg. These AIDS deniers—who have conducted almost no original scientific AIDS research, let alone on the African continent—argue that HIV does not cause AIDS and that the disease does not exist at all in Africa. The estimated 12 million African children orphaned by AIDS have simply lost their parents to the old, endemic diseases of poverty and inadequate sanitation. The full quarter of the adult population thought to be infected with HIV in some African countries carry only a harmless "passenger virus." Mbeki recently convened a scientific panel split almost evenly between mainstream researchers and people who espouse such fringe views, catapulting their notions to center stage. Mainstream scientists—at first reluctant to believe that anyone could fall for a theory with hardly more scientific support than Matia's ideas of witchcraft—are now circulating a sign-on statement declaring that HIV causes AIDS. The prestigious journal Nature plans to publish it. Mbeki—who along with Nelson Mandela is scheduled to speak at the World AIDS Conference—has seemingly backpedaled. Yet there is no doubt that he seriously entertained the denialist ideas. His office solicited the advice of Duesberg colleague David Rasnick, who responded with a letter coauthored by Charles Geshekter, a professor of African history at California State University, Chico, who often takes the lead in arguing that AIDS in Africa doesn't exist. After their surreal letter to Mbeki was made public, inciting a storm of criticism, the South African president penned his own letter to Bill Clinton, comparing the AIDS deniers to antiapartheid activists and medieval heretics burnt at the stake. U.S. diplomats were reportedly so shocked they checked to make sure the letter wasn't a hoax. What makes this all so extraordinary is that Mbeki—who constantly speaks of leading an "African renaissance" in economics, culture, and science, and who says he consulted the dissidents to help avert a "superimposition of Western experience on African reality"—apparently chose to slight African science in his search for an African solution. Instead, he gave disproportionate credence to a group of mostly Western theorists who seem especially ignorant—indeed, almost contemptuous—of science conducted in Africa and the clinical experience of African physicians. Yet African research has provided crucial information to the world's understanding of AIDS, proving, for example, that HIV is not spread by mosquitoes. And now, as the astronomical cost of medication is finally becoming a headline issue, African science is showing that the drugs work every bit as well in African patients as they do in Westerners. In Uganda, many of the scientists who helped discover the epidemic are still studying it. Their story epitomizes the research of a continent. David Serwadda's first inkling was the four patients with Kaposi's sarcoma. That cancer, called KS, is endemic in Uganda, but largely confined to older men who usually get easily treatable lesions on their arms and legs. From late 1983 through '84, when Serwadda was doing his residency in Kampala's Mulago Hospital, four patients—all younger than 45, all from Uganda's rural Rakai District—presented with an unusual form of the cancer that raged throughout the body. One 26-year-old woman originally came in with the lesions on her head and torso, which was unusual enough. But an autopsy revealed that the cancer had invaded her tonsils, stomach, liver, spleen, heart, and lungs. In Zambia, a no-nonsense cancer surgeon named Anne Bayley had also seen this new type of KS—13 patients in 1983, eight of whom were dead by the end of that year. She was virtually certain it was related to the new disease that was killing American gay men, many of whom had aggressive KS, so she started alerting colleagues. Serwadda, too, had read about the new disease among homosexuals, and he wrote Bayley about the KS patients he was seeing. But Serwadda wasn't convinced they had AIDS: "I was thinking, 'The disease is here already? Even in black heterosexual women?' " The chance to find out came in 1984, when the antibody test was developed for HIV, then called HTLV-III. For best results, blood samples had to be fresh, so Serwadda got up before dawn, drew blood and biopsies, and sent them off to London with a passenger who took them as carry-on. But because of a postal error, Serwadda wouldn't learn the results for several months. In the meantime, he was transferred to the medical ward, where he encountered patients wasting away with intractable diarrhea. Many of these patients had a distinctive skin rash or oral thrush, a rare fungal infection that signals immune suppression. "You would ask these patients where they were from," he recalls, "and it was always Rakai, Rakai, Rakai District. That was very strange." What ultimately distinguished the new cases is that they wouldn't heal. Desperate, the doctors tried treating their patients for TB, or typhoid, or malaria, but patients with Slim would not get better, or would only improve for a short time before succumbing to relentless new infections. In their letter to Mbeki, Rasnick and Geshekter wrote, "It is nearly impossible to distinguish the common symptoms attributable to HIV disease or AIDS from those of malaria, tuberculosis, or malnutrition." The speck of truth in this statement is that HIV does not itself cause the illnesses that ultimately kill AIDS patients. Instead, HIV slowly destroys the immune system, leaving the patient vulnerable to whatever microbes circulate in the environment. In the early stages of AIDS, when the immune system is only partly weakened, it can be hard to differentiate an ordinary patient from one infected with HIV. The rare diseases, such as aggressive KS, don't usually attack until later in the illness. That's why Roy Mugerwa, who began practicing medicine long before AIDS, never had a eureka moment. Instead, he recalls, "You observed over time patients coming in with symptoms you can't explain. You are stuck, and that strikes you as queer." TB, for example, is almost always confined to the upper lungs. But in HIV patients, it frequently spreads elsewhere in the body. Who got TB also changed. Mary Mbaziira, a veteran nurse at Masaka Hospital just north of Rakai, remembers that before the advent of AIDS, TB was largely confined to "very poor people or those herding cattle," who contract the germ from raw milk. As AIDS spread, who came down with TB? "People around," she says, gesturing expansively. Geshekter concedes that there may have been an increase in the illnesses associated with AIDS, but claims that any such rise was caused not by HIV but by the economic damage wreaked on Uganda by the dictatorships of Idi Amin and Milton Obote, the wars for liberation, and the imposition of financial "reform" by Western organizations such as the International Monetary Fund. He points to the work of Cambridge University history professor John Iliffe, who documents how public-health spending in Uganda plummeted during the 1970s and early '80s by as much as 85 percent as per capita GDP shriveled. Apart from the fact that Iliffe is "appalled" by Geshekter's interpretation of his work, the poverty theory doesn't fit the facts. In interviews with doctors, Slim patients almost never mentioned food shortages, and Rakai, where the disease originated in Uganda, is very fertile. What's more, war refugees suffered symptoms that were markedly different, recalls Nelson Sewankambo, now dean of Uganda's Makerere University Medical School: "I had never seen the constellation of symptoms and signs that we began to see with Slim." So when Serwadda finally received the test results from those four KS patients, he rushed to show them to Sewankambo. Every one of them had tested positive for HIV. All but one of the control patients with ordinary KS had tested negative. "That's when it dawned on us," says Serwadda. AIDS was in Uganda. Almost immediately, Serwadda started spending his weekends at the medical library, leafing through case notes made by Sir Albert Cook, a missionary doctor who established Uganda's first hospital more than 100 years ago. Cook's renowned case notes, containing his hand-drawn anatomical sketches, "are very detailed and meticulous," says Serwadda. As a doctor treating Slim patients, Serwadda knew what he was looking for—not just the words diarrhea or wasting, but clinical descriptions that matched what he was seeing. He kept going back for months, carefully turning the yellowed, brittle pages. But, he says, "I didn't see it." In the wards, however, he and other doctors were seeing more and more of it. In Zambia, Anne Bayley plotted her aggressive KS cases on a graph and realized that while the total numbers were still small, the increase was exponential—an exploding epidemic. In Uganda, the newspapers started reporting on the strange new Slim epidemic in Rakai, prompting a team from the Ministry of Health to investigate. They didn't test the blood for HIV, but they did allow a brash surgeon named Wilson Carswell to send it, at his own expense, for testing. When almost all of the samples came back HIV-positive, Carswell organized an expedition to Rakai, consisting of himself, Serwadda, Bayley, Sewankambo, Mugerwa, and a taciturn virologist named Robert Downing. At Masaka Hospital and homes in Rakai villages, the team examined more than 100 patients. They diagnosed 29 people as having Slim and sent their blood to England for HIV testing. Every one of those 29 patients tested positive. "I was scared for my country," recalls Serwadda. To learn the true scope of the epidemic and how to control it, Serwadda, Sewankambo, and Mugerwa drafted a research proposal. "These were Ugandans who wrote the proposal, not foreigners who said, 'Do A, B, and C,' " recalls Sewankambo. "I'm proud of that." Maria Wawer, a public-health researcher from Columbia University, later agreed to collaborate with the Ugandans and help secure American funding. The result was the well-known Rakai Project, which is still producing important research. Separately, the Uganda Virus Research Institute and the British Medical Research Council launched another research project in Masaka, which has produced almost 100 scientific articles. In their letter to Mbeki, Geshekter and Rasnick asked, "What evidence is there that people with antibodies to HIV live shorter, poorer lives than people in the same community who do not have antibodies to HIV? We know of no such evidence." In fact, each of these Ugandan research projects has conducted exactly the acid test Geshekter and Rasnick asked for, by looking at HIV-positive people living side by side with those who are HIV-negative. If poverty were the real cause of AIDS, then there should be little difference between the fates of the infected and the uninfected. But the studies found that HIV-infected people died at a rate more than nine times higher than uninfected people. And the Masaka study found that infected people died a full two decades younger, at a mean age of just 34. Even more compelling evidence that HIV is lethal emerged out of a tragic lapse in Kinshasa, capital of the Democratic Republic of the Congo, then called Zaire. When the HIV antibody test became available, Kinshasa's sprawling and impoverished main hospital lacked stores of screened blood and staff to run the tests 24 hours a day. During this window period, children came to the hospital in critical need of a blood transfusion, usually because of malaria. With the child facing death, doctors would transfuse unscreened blood, saving samples from the child and the donor for later testing. In this way, the famous research team Project SIDA, named for the French acronym for AIDS, identified 90 originally uninfected children who were given HIV-infected blood. Among children who survived the illness for which they were given the transfusion, those who received HIV-infected blood suffered a death rate 16 times higher than controls. ------------------------------------------------------------------ "Let me take you back," says Sewankambo. In the beginning, the high proportion of Ugandans with HIV puzzled him. "My thinking was very much affected by the North: This is a gay disease. But if there wasn't that much homosexuality in our community, and we knew there wasn't any, really, then what was the mode of transmission? I was expecting mosquitoes." The mosquito hypothesis was easy to test. Sewankambo and others examined households in which at least one person had AIDS, testing everyone, including children and grandparents. If AIDS was spread by mosquitoes, the virus should be present almost randomly, and certainly it should be in many children, who are the most susceptible to malaria. Nothing of the sort was found. Of the sexual partners of the AIDS patients, a striking 71 percent were infected. Yet of the other people living in the household, with whom the patients were not having sex, only two out of 100 of were infected—a woman who was sexually active and her two-year-old son. "It did certainly suggest strongly that it was sexually transmitted," says Sewankambo. Yet in their letter to Mbeki, Geshekter and Rasnick insisted that the sexual spread of HIV is "merely a very popular assumption," and pointed to a study conducted among couples in California showing that the odds of a man transmitting HIV to a woman during a single act of intercourse are slightly less than one in a thousand. From such first-world studies, they concluded that HIV is not frequently transmitted among heterosexuals anywhere. "Outrageous," says the lead author of that study, Nancy Padian, who is also conducting research in Zimbabwe. "It's more likely that the epidemiology of a disease would differ in different locations than be the same—just look at cancer and heart disease." As for African research, it leaves no doubt that HIV is spread heterosexually. The sex and age distribution of HIV on the continent mirror patterns seen with other STDs. Risk factors for having HIV include more sexual partners, being a prostitute, having had sex with a prostitute, and a history of STDs. In Uganda, two studies stand out. In one, wives were more than 100 times more likely to contract HIV if their husband had the virus than if he didn't. The other study, coauthored by Serwadda and Sewankambo, looked at couples in which one partner had HIV and the other didn't. What they found was shockingly simple: The higher the level of HIV in the infected partner, the greater the chance of transmitting it. This study suggests that if a vaccine could merely reduce the amount of HIV in the bodies of infected people, the epidemic could be curtailed. Clearly, this has tremendous implications for the whole world—and it came from research in Africa. ------------------------------------------------------------------ On the wall of Jane's apartment, just above a gilt legend that reads, "Thinking of you," is a photograph of her youngest son. Daniel had always been a sickly child, but only when he lay in a hospital bed with both kidneys failing was he tested for HIV. That's when doctors tested Jane, but the fact that she was also infected barely registered. "All my heart was on my boy," she recalls. But after Daniel died, Jane's medical records show that she suffered from Kaposi's sarcoma, tuberculosis of the lymph nodes, and painful fungal infections that failed to respond to treatment. One bacterial infection caused an abscess in her thigh, and another infected her blood. Jane felt so tired that she couldn't climb the three flights of stairs to her apartment without stopping to rest several times. "I called in her brothers," says her doctor, Peter Mugyenyi, "and I told them, 'Look, your sister is going to die unless you mobilize money' " to pay for anti-HIV drugs. They did, and she began taking a cocktail of three drugs on September 3, 1999. "By two weeks," says Jane, "I was able to walk up the stairs without stopping." Now, even her KS lesions have vanished and she is worried about gaining weight, not losing it. The AIDS dissidents claim that HIV drugs actually cause AIDS diseases—an absurd notion for Africa, where only a tiny sliver of patients can muster the money to pay for the drugs. Still, Geshekter and Rasnick wrote to Mbeki, "The only blessing of poverty is that it may protect poor Africans from the highly toxic anti-HIV drugs that have already killed thousands, perhaps tens of thousands of Americans." In line with such thinking, Mbeki has questioned whether AZT is too toxic to administer. What's more, his spokesperson, Parks Mankahlana, declared that whether HIV causes AIDS remains an open question "because there's no doctor that injects a human being that has got HIV/AIDS and that person gets healthy in two or three days' time." That's true, but medical science has come closer to curing AIDS than any other viral disease. The drugs do not eradicate HIV from the body; they only suppress it. But once they became available, clinics all over the developed world recorded sharp reductions in disease and death among people with HIV. If AIDS in Africa were merely misdiagnosed old diseases, then the anti-HIV drugs should have no effect or, as the deniers claim, a harmful one. But Jane's recovery is typical of African AIDS patients lucky enough to afford the expensive therapies. Mugyenyi, Jane's doctor, runs the Joint Clinical Research Centre, the main site for a special program that offers the HIV drugs at a discount. Still, they remain so costly that most of Mugyenyi's patients wait until they are very sick before starting therapy. By carefully tracking his patients, Mugyenyi has demonstrated that those like Jane who can afford the recommended three drugs do better than those who can pay for only two. And, says Mugyenyi, the contrast with those who cannot afford any drugs—or who exhaust their resources and must stop the medication—is sharp: Those off therapy almost always sicken and die, while those on the drugs usually get better. But Mugyenyi is going further. He is in the process of measuring how effectively the drugs suppress the amount of HIV in a patient's blood and then "correlating that with clinical improvement." In other words, he is gathering the evidence to show that the better the drugs suppress HIV, the b etter the patient does. "We are demonstrating that here," he says, "in Africa." ------------------------------------------------------------------ Testing the Test Sixteen nations, all in sub-Saharan Africa, have at least a tenth of their adults infected with HIV, according to United Nations figures announced last week. But according to AIDS dissidents, those figures are "meaningless" and no cause for alarm because the HIV antibody test is unreliable. They point out that other microbes and conditions such as pregnancy can create false positive results. And they note that in some African countries, national surveillance is conducted with just one type of test. What they fail to mention are the quality-control measures African countries have put in place. In South Africa, for example, the testers get tested with blood sent by a central lab, and in Uganda, the national surveillance team confirms every positive result with a different type of test. Using these and other measures, both countries have found that the antibody tests are accurate more than 98 percent of the time. These days, there are many kinds of tests, some of which look for material from the virus itself rather than antibodies. For more than 12 years, Ugandan researcher Benon Biryahwaho has helped analyze the tests to make sure they are accurate in his country. "By combining different methods and processes," he explains, "we narrow the window for error." —M.S. ------------------------------------------------------------------ This is a March 20 (2000?) press release from CIPLA regarding its pricing of Nevirapine, a non-nucleoside reverse transcriptase inhibitor (NNRTI). The CIPLA product is called Nevimune. The name is of the Boehringer Ingelheim product is Viramune. CIPLA says it took two years to develop the product, at a cost of Rs 5 core. ($1.1 million in US currency). The announced pricing of Nevimune was 135 Rs per tablet, compared to Rs 344 per tablet for Viramune (about $3 compared to $8 per tab). The CIPLA price for a capsule of d4T was given at 30 Rs (30 mg) to 36.5 Rs (40 mg), or $.66 to $.80 in US currency. This is quite a bit higher than some estimates of the costs of manufacturing d4T. The BMS price for Zerit at drugstore.com is $4.15 to $4.30 per capsule. Zerit is a drug invented at Yale University on a US government grant. The CIPLA price for AZT was given at 10 Rs (100 mg) to 25.5 Rs (300 mg) per capsule, or $.22 to $.56 per capsule. The Glaxo price for Zidovudine at drugstore.com is $1.54 (100 mg) to $4.62 per tab. AZT was also developed by the NIH. CIPLA's press release notes that it is exporting the active ingredient in Nevirapine to Latin America countries.