Aids, a problem with a solution

A child's drawing of a man and a woman in tears is pinned to the wall in the antenatal clinic of the Chris Hani Baragwanath Hospital in Soweto, South Africa. Underneath runs the legend "Aids hurts the ones you love". The poster is next to the condom dispenser.

In South Africa half a million children have been orphaned by Aids and the number is projected to triple by 2010. For perhaps twice that number, their parents are in the process of dying.

Their futures depend on the success of appeals to Western nations to drum up the billions of dollars that will be needed to beat the disease.

Nobody knows what impact this explosion in the number of parentless children will have. Across the continent more than 12 million children have lost at least one parent and the number is expected to rise to 18 million in the next five years.

Not only lives but nations are at risk. In Kwa Zulu Natal, South Africa's fertile coastal province where almost 40 per cent of the adult population is infected with HIV, 27-year-old Nokulunga extends an emaciated arm from under the blanket where she lies to grasp the water bottle by her bed. Ting, her 5-year-old daughter, goes to her mother's side and removes the cap. She is already a carer and soon she will join the ranks of Africa's orphans.

What will Ting's future be? A huge number of children being raised without parental guidance is likely to spell trouble. You see crowds of them congregating at traffic lights in major towns, begging, pilfering, offering themselves for sex. Orphans are more likely than other children to miss school, slip into delinquency and prostitution and pass on the disease.

The impact of Aids on Africa's children is one of many uncertainties about the future of the epidemic, the worst in modern times. The economic future of African nations is also under threat as the disease targets the most productive members of the population - young adults - leaving their dependants, the elderly and the young, without support.

Sub-Saharan Africa is by far the worst affected region, with more than 25 million people infected out of 39 million worldwide. Almost two-thirds of all people living with HIV are in the countries of Africa that lie on or below the Equator, as are more than three-quarters of all women with HIV.

There is some good news. Intensive public awareness campaigns and prevention programmes have resulted in falling infection rates in some countries in Africa, such as Uganda. Governments and political leaders are at last catching up with grass roots movements and speaking out about the need for action. As more leaders speak out, as Nelson Mandela did last week with his admission that his son died of Aids, stigma and discrimination are beginning to lift.

The worst feature of the epidemic in the developing world has been the absence of hope. While HIV has been transformed from a death sentence to a chronic condition manageable with drugs in the West over the past decade, the same treatments have been denied to people in Africa and elsewhere.

The World Health Organisation's "three by five" initiative to get anti-retroviral drugs (ARVs) to three million people - half those who need them - by the end of this year was launched in September 2003. The drugs are beginning to arrive in clinics with the greatest need but just a year before the target date only 440,000 people are receiving them.

Without the drugs to treat the disease, most people see little point in coming for testing. Without testing, people remain ignorant of their HIV status, do nothing to protect their sexual partners and the disease continues to spread. Drugs are essential to underpin prevention efforts.

In July last year, UNAids said US$20 billion ($28.42 billion) would be needed by 2007 for prevention and care in the developing world. This would provide drugs for six million people, support for 22 million orphans and voluntary HIV testing for 100 million adults.

The current level of spending is US$4.7 billion ($6.67 billion). Meanwhile, each day 14,000 more people throughout the world are infected.

US President George Bush pledged to increase US investment in the fight against Aids before his re-election in November. But there are fears the pledge will be eroded by the US protecting its own interests.

Cheaper, generic ARV drugs that have appeared on the market in the past few years are helping countries get national treatment plans under way. But according to Christian Aid this encouraging situation is now being severely threatened by trade negotiations, notably between the US and many developing countries.

The hugely powerful pharmaceutical lobby is using the negotiations to apply pressure to protect its profits at the expense of cheap drugs for poor nations, the organisation said in a report, If not now, when?, published last November.

Drug treatment, however, cannot cure Aids and no matter how extensive, it will not curb the epidemic. Prevention remains critical. The most effective measures are giving people access to condoms, voluntary HIV testing, treatment for sexually transmitted disease and drugs to prevent mother-to-child transmission.

Ten years of efforts to develop an Aids vaccine have yet to show significant progress. But there are other targets for research. Without an Aids vaccine the best hope is for a microbicide, a gel that would destroy the virus during sex and which could be used by women. UNAids said a first generation microbicide could be ready in five years if investment in research were expanded.

An effective microbicide would increase the power of women, on whom the burden of Aids falls disproportionately, to protect themselves. In South Africa, one in four women are HIV positive by the age of 24, twice the infection rate in men. What began as a male disease, targeting male homosexuals, injecting drug users and men who used prostitutes, has turned into a female epidemic. Globally the fastest increase in infections is among women and girls, who now account for 57 per cent of all those infected in Sub-Saharan Africa.

Women are more biologically vulnerable than men, because they are exposed to a larger dose of virus during sex, and their first sexual experience - mostly non-consensual - is often with a man 5 to 15 years older.

This is enough to sustain the disease. As Peter Piot, executive director of UNAids, has pointed out: "If sexual intercourse started between boys and girls of the same age, the epidemic would die out."

For men, Aids is a distant threat. A disease that takes 10 years to kill hardly ranks against all other perils. But for women it shapes their lives. They care for the sick, worry about passing on the virus to their unborn children, and worry about who will care for them when they are gone.

The feminisation of Aids and the need to focus support on women has dawned only slowly on the major international organisations. In its latest report, published to coincide with World Aids Day last December, UNAids admitted the strategy to prevent Aids must be re-written with a new focus on women.

The best news from sub-Saharan Africa is that the epidemic is stabilising. But this is only because the number of people dying has risen to equal the numbers becoming newly infected. To reverse the trend poses an extraordinary challenge on technical, social and economic fronts.

It can be done according to Peter Piot, executive director of UNAids. Prevention efforts are starting to work in certain places. "From Addis Ababa [Ethiopia] to Lilongwe [Malawi] we are seeing a decline in new infections, especially among young people. This is a problem with a solution."

- INDEPENDENT