Stuart Loory, Lee Hills Chair in Free-Press Studies, Missouri School of Journalism: HIV and AIDS, which affects some 33 million people around the world, is no longer the talked-about issue it was just a few years ago. There is no vaccine in sight for this viral infection, although researchers have not stopped trying to develop one. In the meantime, the way to control the impact of the disease is through the use of antiretroviral drugs that slow down or stop the spread of the disease in the human body. The drugs are expensive, costing up to $19,000 a year per treated person in the United States but less than $100 a year in developing countries. Still, in a country like Uganda, it costs $11,500 a year to treat AIDS patients, and the number of newly infected far exceeds the number who are getting the drugs. Major donors from wealthy countries around the world are losing interest in combating AIDS. They say the money could be better spent preventing malaria, typhus or tuberculosis, that more lives can be saved with the same amount of money or less and that in these economic times, giving cannot be increased. So in some African countries, new HIV/AIDS cases cannot be treated while older ones hold on. Treatment of AIDS seems to be coming under control in Uganda, but there are stories that the problem is once again growing more serious. Why is that?
Joshua Kyalimpa, president, Uganda Journalists Association; Kampala, Uganda: The number of people infected by AIDS in Uganda starts at 1.2 million. Of this, only 400,000 have access to drugs. Of course, the infection rates were even higher in the early 1980s; they were around 30 percent, but then there were campaigns where you had messages on radios and billboards. Around 2006, the infection rate was 5 percent. Today we are talking about infection rates of about 6.4 percent. The Uganda AIDS Commission thinks the rates are the result of complacency — that people are used to the message of HIV, and they don’t fear it any longer.
Loory: There are also hunger problems, and it is hard to take the antiretroviral drugs without being able to eat a lot because it gets very painful. There is also the question of money being donated. How serious are those problems?
Kyalimpa: Lots of money has been coming in from the United States. Some people are arguing that most of the funding has been going to moralistic campaigns while some of the other strategies, such as use of condoms, have been ignored. Also there are people getting HIV who are sick but cannot get treatment because if the HIV count goes up to a certain level, then you don’t have access to treatment.
Loory: How are things progressing in South Africa now that the government has been more open about the problem?
Anso Thom, print editor, Health-e News Service; Cape Town, South Africa: It has made a big difference. We had almost 10 years of political apathy around HIV, and the main struggle was getting people to treatment. That time has passed, but it is a very sober realization we’re not going to treat our way out of this epidemic. No matter how many people we put on antiretrovirals, we simply cannot afford to, and very few countries will be able to afford it. But government has just launched a massive HIV counseling and testing campaign, so anyone who comes to a state health institution and some of the private-sector health facilities will get an HIV test. There are a lot of people out there who don’t know their HIV status. We have to make people who are HIV positive get access to treatment and those who are HIV negative to remain negative. We also started to implement our male circumcision campaign, but one of the biggest issues still is that we need something that women can use as a prevention method. The results have been disappointing, but we are hoping that something will still come out of that. The political response has been a great relief because we can focus on the issues that we should have focused on years ago.
Loory: How should the AIDS situation be handled — through prevention or treatment of those infected?
Emi Maclean, U.S. director, Doctors Without Borders — Access to Essential Medicines Campaign; New York: The concern we have at Doctors Without Borders is we don’t want the last five or six years to be a golden age of treatment that is now over. We’ve seen really effective treatment in a number of countries taper off alongside care and prevention programs, and it is really important to recognize that there is not a divide between prevention and treatment. You can’t say we’re going to do treatment now and we’re going to do prevention later or vice versa. They’re really two sides of the same coin. With effective treatments, studies have shown that the chance of transmission of HIV from one person to another decreases by more than 90 percent. So we have been involved in providing treatment in over 30 countries now, and we have seen a number of other actors step up over the last decade, including countries like Uganda and South Africa. Especially in the last year or so, South Africa has made tremendous strides on this, and we’re starting to see some real population level effects, especially in places where coverage is high. We don’t want to be backtracking now, and there is a lot of questioning about whether we can continue in this way, but we’re really nowhere near the point where we need to start that kind of questioning.
Loory: Brazil has had a pretty effective treatment program, as I understand it, and has been one of the models around the world for how to deal with the problem. What is Brazil doing that other countries are not doing?
Oliver Bacon, author, HIV/AIDS in Brazil, AIDS policy research center; San Francisco: One of the things Brazil did in the 1990s was not to separate treatment and prevention. They had been aggressively pursuing both prevention — condom distribution, public education campaign — and publicly funded free-access antiretroviral therapy. One difference about Brazil to note in contrast to the countries we are discussing today is that in Brazil, the proportion of people who are HIV positive is still under 1 percent of the general population. Many people have argued that it was Brazil’s early approach to the HIV epidemic that allowed them to maintain a concentrated epidemic rather than a generalized epidemic. But there is a somewhat famous bit of data analysis that the World Bank in 1994 estimated that by 2004 Brazil would have 1.2 million HIV infections and as a result of their aggressive program, they actually had around 500,000.
Loory: I take it that the situation is concentrated in the United States rather than generalized. How is treatment going, given that the cost of the drugs in this country is so expensive?
George Curry, columnist, Philadelphia Inquirer, National Newspaper Association; Washington, D.C.: It is amazing to me that the United States remains so skittish about the idea of condoms. I went to a National Conference on AIDS in Bangkok and people said no big deal, and I have read about in Brazil where they pass out condoms in taxi cabs. We’re nowhere near that, and that is a major impediment. One of the most important things to happen here in the United States is the shifting of AIDS. African-Americans, for example, have gone from 25 percent of HIV cases to almost 50 percent. African-Americans are 12.7 percent of the American population but half of all AIDS cases. African-American teenagers are 16 percent of the teenage population and 69 percent of all AIDS cases. Black women account for 66 percent of all new AIDS cases among women.
Loory: Are the drug companies still doing enough to lower the price of ARVs in the United States?
Curry: I don’t think so at all, especially when you see the discrepancy between what they charge overseas versus here. But people shouldn’t forget that the pharmaceutical industry is the most profitable industry in the United States, and there are so many campaign contributions that a lot of lawmakers are beholden to them.
Loory: Why is the drug so expensive in the United States and so much cheaper around the world? Is that because of the drug companies’ venality or what?
Maclean: It really has to do with inflexible property laws. Patent protections in the United States mandate 20-year monopolies for a drug company or another inventor. They are much cheaper in other countries because those countries have had different patent laws in the past that allowed them to build up a generic industry.
Loory: At $19,000 a pop for a year’s treatment, are the drug companies making an obscene amount of money? Are they selling it for that when they can really make a profit at $100 a person for a year?
Maclean: Doctors Without Borders doesn’t work on HIV/AIDS in rich countries. We work on medical issues that are affecting developing countries. We definitely have concerns about the price of drugs, and a lot of that comes from the fact that there is a monopoly. There are arguments about how much it costs to compensate research and development. One of the arguments we made at Doctors Without Borders is that there should be a mechanism to separate the cost of research and development from the price of the drug so that you are not negatively affecting access to medicine based on the argument about the need for compensation.
Loory: There is a consortium being set up of drug companies around the world to make the drug available in developing countries for less money — is that right?
Thom: All I know is that South Africa has now the help of a foundation that pools all the countries as one buyer. South Africa is taking advantage of this and hoping to get much cheaper drugs.
Maclean: The international consortium you were referencing is UNITY, which is international financing partly funded by a small tax on airline tickets in Europe. The purpose is to support the creation of a patent pool for AIDS medicines, which would allow the licensing of medicines so they could be used in developing countries. It is a really important tool because some of the early drugs that have been produced in India, Brazil and some other countries are more affordable, but some of the more recent drugs are now very expensive.
Loory: What about the feeling in donor countries and in donor organizations that it is more effective to use the money that is going into AIDS treatment and prevention to treatment of other diseases that can be handled more easily?
Bacon: There is a considerable amount of debate over that question. I wouldn’t say that is a universal feeling in donor countries. Certainly the groups that I work with would argue quite strongly against that proposition.
Maclean: You can’t pick one or the other. One of the conversations you hear now is that we’re going to focus on maternal and child health and we won’t be able to devote as much time and energy to HIV/AIDS. That is a ludicrous proposition when you know that the greatest killer of women of reproductive age is HIV/AIDS. We’ve made enormous progress as an international community over the last five or six years in helping to begin to tackle the HIV/AIDS epidemic, but we have come nowhere close to being able to step back now.
Loory: Can you talk about AIDS versus hunger, malaria and other diseases in Uganda? Is treating those problems more effective than treating AIDS?
Kyalimpa: Most of the funding for HIV and malaria has been coming to Uganda from the Global Fund. Now the Global Fund for Malaria, AIDS handles most of the funding in Uganda and relies on donor funds and with instructions on how it should be used.
Loory: As we have been hearing on the "Global Journalist" program over the years: There are many ways tragedy can strike — war, pestilence, disease, poverty, natural disaster, human misgivings. None is as heart-wrenching as prolonged serious disease.
Producers of Global Journalist are Missouri School of Journalism graduate students Youn-Joo Park, Angela Potrykus, Melissa Ulbricht, Tim Wall and Megan Wiegand. The transcriber is Pat Kelley.
Stuart Loory has been the founder and moderator of the weekly radio program “Global Journalist” for 10 years. This was his last program. He is retiring from the Missouri School of Journalism and leaving Columbia. The program will continue to air at 6:30 p.m. Thursdays on KBIA/91.3 FM or at www.globaljournalist.org. Next week, Professor Charles Davis will moderate. The program is also available live at www.rjionline.org at 8:30 a.m. Thursday mornings.