Africa's Best Hope: Anti-Retrovials
By Oakland Ross

SOWETO, South Africa: She is two years and four months old, her first name means "acceptance" in Zulu, and if she were true to her name, she'd be dead by now.

Instead, Samakilisewe Mthimkhulu is a chubby little girl, bursting with life.

Barefoot, in a pair of hand-me-down red shorts and a red top, she wriggles on her mother's lap in the weathered little home they share along with five other children and a disease called AIDS, as the bronze winter sun drifts westward over Soweto.

In order to keep death at bay, Samakilisewe is obliged to swallow a spoonful each of three liquid potions every morning, potions that bear the outlandish labels of faraway pharmaceutical firms: Bristol-Myers Squibb, Boehringer Ingelheim, GlaxoSmithKline.

She does her duty without a fuss.

"She likes the medicine," insists her mother, Bongiwe, 32, who is HIV-positive herself, as are two more of her children. Only Samakilisewe so far has AIDS. "She even reminds me when it is time."

Unfortunately, not all South Africans are so diligent, starting with the health minister.

If she could, Samakilisewe would be perfectly justified in marching up to South Africa's minister of health and telling her to go take a flying leap into the nearest reservoir.

Health Minister Mzanto Tshabalala-Msimang, following the lead of President Thabo Mbeki, continues to cast doubt on the efficacy of a new generation of drugs known as ARVs, or anti-retrovirals: drugs that have saved countless lives in Europe and North America and that now offer hope to millions in Africa, when they are available.

In South Africa, for the most part, they are not.

"It's bizarre, it's irresponsible, it borders on the criminal," says Nathan Geffen, spokesman for the Treatment Action Centre, a South African agency that lobbies for greater access to these life-saving drugs. "There are a number of obstacles, but the one that stands in the way is the lack of political will."

The cavalier policies of the South African government constitute just one of the hurdles obstructing the provision of AIDS treatment in Africa, and they apply only to that country. For the rest of sub-Saharan Africa, governments are mostly willing but lack the means, the skilled personnel and the resources to make treatment widely available.

A timely and generous response by wealthy donor nations might have gone a long distance toward alleviating the continent's plight, while saving millions of lives in the process, but that is not exactly what has happened.

"The level of delinquency on the part of the western world is astonishing," says Stephen Lewis, the U.N. envoy for AIDS in Africa. "I feel quite frantic about it."

As a result, in the part of the world that needs it most, ARV treatment has been late to begin, and distribution remains spotty and slow.

Meanwhile, people are dying, people whose lives could easily be saved.

Consider Samakilisewe Mthimkhulu, who as recently as this past March was gravely ill, thin as sticks, and drifting toward death, until she was put on ARVs.

Beginning on the eighth day of March, she rose again.

Since then, three white plastic bottles of medicine have made all the difference in the world to this one child in this one block of red-brick shelters located in this sprawling African suburb to the south of Johannesburg.

Samakilisewe is a very fortunate girl, one of the fortunate and the few.

Taken together, some 5.6 million of this republic's 44 million citizens are HIV-positive, possibly the largest concentration of such people in the world, challenged only by India.

Of these people, roughly 700,000 now are sufficiently compromised by AIDS that they require anti-retroviral treatment or they will surely perish, long before their times, just as thousands in this country, and more than 17 million people in all of Africa have already done.

At present, however, only about 40,000 South Africans are receiving ARVs, a minuscule proportion of the sick and dying, and a rate of treatment that is far eclipsed by nearly all of this country's much poorer and far less developed neighbours.

Of all the problems that now confront this continent, none is more potentially catastrophic than this virus passed from blood to blood during sexual intercourse.

Only a few years ago, there was no hope of saving millions of people already infected with HIV, and instead African governments and international aid agencies threw most of their energies into trying to stop new infections from occurring, itself a wrenchingly difficult task.

Everyone now agrees that it is horrendously difficult to change people's behaviour, their cultural or sexual patterns, even when life and death are at stake.

"Behaviour change is the biggest challenge in prevention," says Derek von Wissell, head of the government anti-AIDS program in Swaziland. "I don't think anybody has cracked the nut of behaviour change."

Still, health authorities in a host of countries have done their best. They have issued dark warnings about the threat of AIDS. They have put on plays in schools, dramatizing the dangers of unprotected sex.

They have sent former commercial sex workers into African beer halls armed with condoms and wooden dildos, to demonstrate to hordes of inebriated men how the two go together.

They have promoted sexual abstinence and monogamy, and they still do.

Prevention of new infections remains the central strategy in the struggle against AIDS in Africa.

Yet millions of people continue to engage in unsafe sex, for many reasons.

In many areas, condoms are simply not available.

Besides, to people who are seriously hungry today, the potential consequences of HIV infection (death in eight or 10 years) might seem a somewhat distant and unreal prospect and therefore a poor disincentive.

Finally, sex in Africa is not typically conducted between two equal and consenting adults. Women and girls are at a clear disadvantage both culturally and economically, and they rarely determine the terms of their relationships with men.

Here in South Africa, at least one organization has eschewed the sort of bleak, moralistic warnings that have long been the staple of AIDS-prevention campaigns on the continent.

"Our focus really is around positive lifestyles," says Scott Burnett, an official at LoveLife, a hip, upbeat AIDS-prevention agency in South Africa. "It's not about wearing condoms. It's about being positive about your future."

The agency's edgy slogan is "Get attitude."

"You, your future, your dreams," says Burnett. "That's our message."

Here's hoping it works.

In the meantime, however, people continue to contract and succumb to a disease whose ability to kill is proving even more formidable than the experts used to believe, and that is saying plenty.

"The early theories were that it couldn't hit 40 per cent," von Wissell says. "That is now thrown out the window."

In several southern African countries, including Botswana, Lesotho, and Swaziland, 40 per cent and more of the adult population have already been infected. Malawi, Zambia and Zimbabwe are not far behind.

If there were a cure for AIDS or a vaccination against the disease, then almost everything would change. But, so far, there is neither.

For Africa, for now, the best hope resides in just three bottles of pills, multiplied over and over again, the standard triple-drug regimen of anti-retrovirals that is already saving and enhancing tens of thousands of lives on the continent.

Unless you happen to be the South African minister of health, the effectiveness of these medicines is impossible to deny.

Tshabalala-Msimang would be well advised to pay a visit to Cotlands, an AIDS orphanage located in Turffontein in the south end of Johannesburg, where there are always at least 60 youngsters prancing about the brightly lit corridors or resting in the dormitories, with their Shrek 2 bedspreads and stuffed animals.

"I'm a firm believer in anti- retroviral treatment," says Allison Gallo, who works at the orphanage. "I've seen the condition of our kids improve dramatically."

The orphanage's facilities include an 18-bed hospice, where staff workers provide palliative care for seriously ill children, some of whom are in the final stages of AIDS. A few youngsters, unable to breathe on their own, are hooked up to oxygen tanks. Others are excruciatingly thin, the epitome of starving babies.

Prior to the introduction of ARV treatment at Cotlands, the orphanage was losing children to AIDS at the rate of three or four a week, says Gallo. There was nothing to do but care for them until they died.

What a difference a few drugs make.

So far this year, only five children at the orphanage have died of AIDS, a nearly miraculous turnaround.

"Many children come in looking really dreadful, and we don't think there's much hope," says Gallo. "But, after a few weeks, there's a tremendous difference."

In many poor African countries, the will exists to provide treatment for AIDS, but there is a woeful lack of "capacity": physical and organizational resources and skilled people to make use of them.

In Malawi, for example, there are just 350 or so doctors in a population of about 12 million people. Only two of those doctors are pediatricians.

In Swaziland, ARVs are available at only five government hospitals, where they are provided free of charge. But that's not much help if you live in the country's eastern lowlands, where the nearest government hospital is in Manzini, a four-hour bus ride away. The journey costs 20 emalangeni, equivalent to about $3.65 (Canadian) or 15 per cent of the average rural-dweller's monthly income.

And so people die.

But the dead do not include Nokhwezi Hoboyi, even if she has lost two newborn children to AIDS.

The young Cape Town woman was infected with HIV in 1998, but her doctor refused to tell her so. She lost her first baby, then another, and finally became very ill herself.

By 2002, she was passing out at work, and it was only then she found out that she had AIDS and she was dying. She would have died, too, were it not for ARVs. Now she takes two pills in the morning, three at night.

"A lot of people have died without being able to access treatment," she says. "They have died without knowing their options."

And, by the tens of thousands, Africans continue to die, deprived of the medicine that surely could save them.

"I have improved," says Hoboyi who, at age 25, has a long life ahead of her. "I feel very much great."

But she is one of the fortunate, the fortunate and the few.