Aids has no cure - remember?

Durban, South Africa -- When 40% of your working age males are HIV-positive, it's hard to be optimistic about your country's future. But at the World Economic Forum summit held in Durban last week, Botswana's President Festus Mogae was determined to be upbeat, advocating AIDS prevention and treatment with almost every sentence. Admirable though his passion may be, effective AIDS treatment, much more so than prevention, confronts a host of potentially insurmountable barriers in Africa. Meanwhile, the international community's continuing overemphasis on AIDS masks the immediate and larger threat of malaria and respiratory disease on the continent -- ailments that are genuinely curable.

One reason for Mr. Mogae's optimism is the fact that the private sector, including the drug company Merck and the Bill and Melinda Gates Foundation, has stepped up its efforts to combat the pandemic. Botswana's lead has encouraged countries such as Mozambique and Kenya to better expel myths about AIDS. But powerful African nations like Nigeria and South Africa still seem to be wavering on action. South African President Thabo Mbeki continues to flirt with widely discredited theories that HIV does not cause AIDS, undermining the whole basis of Western approaches to treating and preventing the disease.

Private initiatives alone cannot alleviate the AIDS pandemic. At roughly $200 per person, Botswana's annual per capita health budget is the continent's largest; many African nations spend less than $10. The African country most capable of taking action, Botswana has thus far concentrated on prevention, and has been rewarded by a slowing of new HIV cases. As the number of AIDS cases continues to rise due to the long lag time between HIV infection and full-blown AIDS, the Botswana government has also been trying to improve treatment, and with some success.

The Gates Foundation has donated $50 million over five years toward this effort, a grant matched by Merck, which also supplies many antiretroviral drugs free of charge. Accordingly, AIDS patients in Botswana are beginning to live longer. Proposed drug donations by Boehringer Ingelheim, Pfizer, GlaxoSmithKline and Roche will also help control opportunistic infections associated with the disease.
Nevertheless, for much of Africa this approach is not currently feasible, due to low capacity to deliver treatment. The monitoring, testing and treating of someone with AIDS is an onerous task. We all know how easy it is to forget to take a pill. Yet while for most infections it matters little if it's taken a few hours late or early, for antiretroviral treatment timing is crucial. Even an hour off can cause problems. Each of numerous pills has to be taken every day for many weeks.

Mistimed treatments lower efficacy and encourage resistance, which is one of the reasons why in some parts of the U.S. there is HIV resistance to the drugs of 25% (nationally, it averages around 10%). So it's easy to see why a 1998 survey by the U.S. Centers for Disease Control found a 75% HIV drug-resistance among U.N.-treated AIDS patients in Uganda (now widely seen as an AIDS success story), where clocks and watches are scarce.

Drug companies are naturally concerned about high levels of resistance spreading back to their main markets in the West, since resistance makes their drugs obsolete. Africa's widespread incapacity to test who should have what doses of what medicines, then to deliver medicines correctly every hour of every day, is the real stumbling block for AIDS treatment in Africa. According to Amir Attaran of Harvard University it costs at least $900 per person per year simply to deliver AIDS drugs, and that's before paying for the drugs themselves, which can run into thousands of dollars.

Of course, numerous drug companies have bowed to both internal and external pressure to donate their drugs at cost or for free. Consequently, numerous companies operating in Africa have stepped in to assist proper treatment, either with their own clinics and hospitals (such as Unilever, Billiton, Shell and Anglo American), or by funding others (such as Exxon, Nestle and Heineken).

But the unintended consequence of such corporate action is to polarize communities. Employed families get treatment; those outside the "working community" do not. Unilever, for example, would like to help those outside its corporate tea plantations, but is having to face the extreme difficulty of delivering medical support, let alone complex AIDS therapy, in rural areas.

If private redress risks dividing a country into treatment haves and have-nots, so does the public variety. Most African governments cannot guarantee countrywide access to treatment. While more logistically tenable urban programs might quell the clamoring of the most vocal and organized lobbyists, dispersed rural residents would inevitably go untreated. This unhappy prospect may explain Mr. Mbeki's flirtation with offbeat HIV theories, as denying the efficacy of antiretrovirals excuses inaction.

Many aid agencies realize that AIDS programs and highly publicized price-slashing by pharmaceutical companies raise popular expectations, while their budgets only allow for short-term, small-scale trials. Crucially, AIDS programs are expensive and will divert funding from child immunization, oral rehydration therapy for dysentery, removal of malaria mosquito breeding grounds and delivery of clean water, all of which save many more lives at much lower cost than AIDS prevention, let alone treatment, which only delays death and does not cure.

Kofi Annan, director-general of the United Nations, has called for an anti-AIDS fund of $10 billion a year, widely endorsed at the WEF meeting last week. The only agency with access to funds of that magnitude is the World Bank, which like all Bretton Woods institutions was not established to give money away. Indeed, large loans allocated over decades to health care will never, in practice, be repaid. Instead we would doubtless see a repeat of poorly performing loans of recent years, with further calls for debt relief.

AIDS patients and caregivers don't care where the money comes from, and regard time as too short to establish a whole new agency to distribute funds. One minister from a developing country, who didn't want to be identified, thought the money should justly come from the World Bank since it has been "structurally maladjusting us in recent times, and should do something useful for a change." But honey pots full of money in Africa tend notoriously to leak. And barring staggeringly vast investments in infrastructure like paved roadways continentwide, even a generous fund like the one Mr. Annan commends would not remotely overcome Africa's treatment-delivery problems.

It does seem inevitable that an AIDS fund will be established, probably run by the World Bank, which will bring treatment to many AIDS victims in Africa. Anyone arguing against such a fashionable, seemingly beneficent program will earn himself few friends. But it does seem paradoxical -- nay, tragic -- that the world may end up spending tens of billions of dollars annually to provide painful, only moderately successful treatment to prolong life, while not making millions of people healthy from curable diseases like malaria for only a few billion. In these days of emotional politics, perhaps the rich world will only spend money on diseases with which it has some familiarity.