Around 40 million people are currently suffering under the burden of HIV/AIDS and perhaps 27 million of them are Africans. It is tragic to think that while 6 million Africans could probably benefit from treatment, fewer than 450,000 are receiving any. Meanwhile infection continues at a rate of perhaps 12,000 a day.

There are many, many reasons why Africa has the worst HIV problem, and you will be aware of most of them. They are easy to list, relatively straightforward to analyze, but so far, have proved extremely difficult to overcome. Some of the reasons are due to the nature of African countries, others to do with the nature of the virus, and a few to do with the nature of aid and aid givers.

African problems

Key on the list is poverty. Without sufficient wealth at least for a decent diet, human immunity is vulnerable to infections and HIV is a king of opportunism. There is little capacity within the health system--there are very few doctors or nurses (450 doctors per 100,000 in U.S., 7 in Zambia), nor money to buy drugs or even condoms in many communities. But far worse, often because of lack of education and strong sexual stigma, there is no political will to correct risky behavior. The corollary of this is the extreme reluctance of western aid agencies to tackle infection and many other blood-borne diseases through injections and transfusions. Last, Neo-Marxist economic policies, which were initially understandable as a backlash to colonial rule, no longer hold any credibility.

HIV Problems

HIV is a rapidly mutating virus. It is therefore very difficult to attack in a sustained way, and there is no cure. Treatment has to be done with triple drug therapy to prevent resistance build up--this is very expensive (not just the cost of drugs, but the testing regime as well--viral loads/CD4 counts), and a high level of staff competence is required.

Aid Problems

The history of aid is far from glorious. Numerous papers have demonstrated that far from helping development, long term aid has often displaced private sector work, and even encouraged corruption through guaranteed funding without proper accountability. Past failures have often led to policies that are inconsistent with the stated aims, and follow a path of least resistance rather than the best path. AIDS is a long run problem, especially susceptible to the general failures of long term aid.

New Problems

Additional problems are being created. The current preoccupation is with treating lots of people with anti-retroviral drugs. The World Health Organization has set a target for three million to be on treatment by the end of this year. UNAIDS chief, Dr Peter Piot said that the rate of increase currently underway (up 75% from last year at 700,000) means that it is possible to achieve that aim. But the veracity of this number is dubious. Inside sources claim that at least 69,000 of those being treated are double-counted, since programs in poor country locations are claimed by more than one participating agency. One AIDS expert claimed the number being treated in poor countries, that international agencies can lay claim to, could be as low as 480,000.

But even if 700,000 are on treatment--is setting a target of three million a good idea? If the aim is to increase funding, and dramatize the urgency of the disease then perhaps yes, but is it helpful?

The only successful and sustainable programs, whether private sector, aid driven or governmental, have taken time to develop. Mass education programs and anti-stigma campaigns, such as those in Uganda, have had a large impact relatively quickly, but no successful treatment program has been a quick fix. The Merck, Gates and BMS programs in Southern Africa have taken years to get a substantial number of people on treatment and these programs are sustainable (assuming continued funding) because of good clinical management, local health community involvement, political will, and consistent availability of high quality drugs.

The infrastructure required to deliver such programs is extremely complicated. Only Brazil and maybe Thailand have sustainable home-grown programs, not involving the much-maligned research-based industry. Although sadly, drug resistance may be becoming a problem in Brazil.

As success is so rare, those programs that are well run are at risk of being overloaded by aid agencies. The desire to treat more people is noble, but to satisfy a contrived target, some of these good programs may be compromised. This would be unforgivable.

We have to accept that treating three million people by the end of this year is not possible without making dangerous, immoral decisions. The controversy over the withdrawal of (generic) drugs rushed through WHO pre-qualification to meet the treatment target is still rumbling. But there is no doubt that poor quality drugs are being used, and this must stop. To put people on treatment without proper testing, care or even without known drug quality is wrong, even if it is born out of desperation.

I am hopeful that sense can prevail, but it is essential that medical experts stick to what is achievable, not what the marketing men and fundraisers want.

Roger Bate is a resident fellow at AEI.