22 million dead. (The Last Word).

Discussions of the HIV/AIDS pandemic in Africa invariably focus on the high cost of antiretroviral (ARV) drug therapy. ARV is an effective tool in the fight against the disease, but it is terribly expensive. In the United States, a year's regimen of brand-name ARVs costs between twelve and fifteen thousand dollars per patient. While it is true that major U.S. drug manufacturers have devoted large sums of money to fight hiv/aids in developing countries--by reducing the price of ARVs, investing in medical infrastructure and education programs, and even providing less expensive generic versions of the drugs--the haunting fact remains that most families in the developing world simply cannot afford the drugs, even at discounted prices.

Still, the drug companies alone cannot ensure access to ARVs for all those who need them. UN Secretary General Kofi Annan has estimated that $10 billion will be needed annually to fight aids globally, and even that will fall far short. Expecting much more from for-profit drug companies is asking them to act against their own legitimate interests. Nor, as a society, should we attempt to shift the burden of our collective responsibility onto the shoulders of one particular group.

The death toll from aids already stands at 22 million people. Forty-two million are currently living with HIV, and new infections are occurring at a rate of 5 million per year. The plague is advancing quickly into China and India. In sub-Saharan Africa, 58 percent of infected adults are women. This is having profound social and economic effects in Africa, where women do most of the work on subsistence farms and are responsible for food preparation. In addition, they are more likely to be invested in the education of children than men are. When a family member becomes ill, women are the caregivers. The implications are staggering. Meanwhile, only 1 percent of hiv-positive Africans receive ARVs.

Yet aids can be beaten back: we have some very effective tools in education and prevention. In the last decade, Uganda has driven down the HIV prevalence rate among pregnant women in its capital from 30 percent to 11 percent. Senegal has held the rate among adults to 0.5 percent. In South Africa, HIV prevalence in pregnant women fell to 15 percent last year, down from 21 percent in 1998. In Addis Ababa, Ethiopia, prevalence in women at prenatal clinics was 15 percent in 2001, down from 24 percent in 1995. Elsewhere, Brazil and Thailand have shown some success in fighting the virus.

If, as part of a global initiative against HIV/AIDS, the United States were to take responsibility for procuring ARVs from drug companies for global distribution, very attractive prices could be negotiated. As the major purchaser who could guarantee continuing purchases over many years, the U.S. government could probably negotiate prices that would be less than 10 percent over the base cost for producing the drugs. Furthermore, this would epitomize the best features of free-enterprise capitalism, rather than the socialist approach of nationalizing the drug companies, as some have suggested.

It is clear that a multiyear, global program in the $20-billion-a-year range can be carried out only by a worldwide consortium led by the United States and allied with the UN. Americans are not unfamiliar with such sums. The projected cost of war with Iraq, according to some knowledgeable experts, may run as high as $100 billion. Imagine if we were able to avoid the war and a similar commitment could be made to stemming hiv/aids. The administration's 2001 tax cuts will shrink tax revenues by an estimated $1.3 trillion over ten years, and that does not include the president's most recent tax-reduction proposals. What if we were to forgo some tax cuts? It is clear a war on hiv/aids would not be a budget-buster; it is simply a matter of deciding how to set our priorities.

A global offensive against HIV/AIDS led by the United States would have the clout to overcome serious political barriers. During a trip to India late last year, Bill Gates was well received by India's elites for praising the country's high-tech potential. Yet when he warned of the looming aids crisis, India's health minister accused him of "spreading panic." Gates had been quoting from a U.S. government study which projects a rise in the number of HIV cases in India from around 4 million to about 25 million in 2010. One way to insure the spread of the virus is to accuse those who warn about it of heightening panic.

The United States has an opportunity to demonstrate that, important as the struggle against world terrorism is, the struggle against HIV/AIDS is equally critical. We can no longer stand back and let this global pandemic run its course. If we do, we will lose all moral claim to global leadership. Some day our grandchildren will look back in shame and wonder how we could have allowed a known, treatable enemy to kill so many. n

Francis Xavier Cunningham, a retired Foreign Service officer, had assignments in Brussels, Manila, and Cairo.