Answering one question . . .

asking a thousand.

Today is World AIDS Day, of course, and as it happens, there is relevant news. An effort to treat people living with HIV in Port-au-Prince, Haiti, has shown great success in its first year. Haiti is the poorest country in the Americas. Its approximately 8 million people (an accurate census does not exist) have a life expectancy at birth of 53 years. The infant mortality rate in Haiti is about 73/1,000 births, and the adult literacy rate is just over 50%. Haiti also has the highest prevalence of HIV in the Americas, at about 5.6% of adults, which means there are 280,000 Haitians living with HIV. (These are estimates from 2003. There is some evidence that prevention campaigns have reduced HIV transmission, which mean the prevalence will be declining as people with HIV die.) Haiti, in other words, resembles poor African countries.

Back in June 2001, the Director of the U.S. Agency for International Development, Andrew Natsios, told a Boston Globe reporter that there was no sense providing anti-retroviral treatment to Africans because they would be unable to adhere to the drug regimens, which require taking doses consistently and on time. Natsios said, specifically, "Africans don't know what Western time is. Many people in Africa have never seen a clock or a watch their entire lives. And if you say, one o'clock in the afternoon, they do not know what you are talking about." Earlier in the year, one of those "anonymous senior administration officials" had told the New York Times essentially the same thing.

Natsios was justifiably excoriated for his ignorant, racist comments, but even after losing that particular excuse, the Bush administration continued to fight efforts to allow poor countries to manufacture or purchase generic versions of HIV medications (all of which are under patent and very expensive), and has provided far less in assistance to poor countries for HIV treatment than it has (repeatedly) promised. Haiti and African countries cannot afford to provide even generic drugs to their large populations living with HIV -- only the rich countries can make that possible.

Well, we already know that anti-retroviral drugs can be used effectively in poor countries. Brazil has led the way with an aggressive, successful program, but in most of Africa and in Haiti, few people with HIV have access to drugs. Today we learn, from a report in the New England Journal of Medicine (subscription only, news story is here), that a team of Haitian health care providers that has been providing antiretroviral treatment to 1,000 people, still has 87% of its patients alive after one year, including almost all of the children. It appears they didn't have a control group per se, but based on the natural history of the disease in Haiti, they estimate that expected survival without medications would be about one-third of the cohort.

Okay then, let's give antiretrovirals to all 280,000 Haitians living with HIV! Well, not so fast. As the investigators say, these folks were living without running water or sewers. Like most Haitians, they didn't have enough to eat. Some of them were TB positive or had active tuberculosis or other diseases. The doctors gave them food, and took care of their other medical needs, which undoubtedly contributed to their survival at least as much as the ARVs. Providing antiretroviral medications to 280,000 people would cost a lot of money. If somebody is willing to step up and spend that money, will somebody provide 8 million Haitians with clean water, sanitary sewers, an adequate diet, decent housing, education, economic development and jobs, and basic medical care? If not, why should somebody provide 280,000 of them with expensive medications that will probably keep them alive for one year, but as far as we know so far, may not keep them alive for two? I'm just asking the question, I'm not anwering it.