A CONTINENT AT RISK.

Millions of Africans are dying of AIDS because they can't afford the drugs that could save their lives. Now there may be some hope.

FOCUS: In Africa, Millions of AIDS Patients Can't Afford Drugs That Prolong Life

TEACHING OBJECTIVES

To help students understand the dimensions of the AIDS crisis in Africa, where 17 million have died and the death toll keeps rising, and how reduced drug prices and access to cheaper generic drugs may offer a glimmer of hope.

Discussion Questions:

* Are drug companies guilty of gouging AIDS victims, in the U.S. or Africa?

* Is breaking a patent a case of "stealing ideas"? Is it ever justified?

* Should the U.S. government prohibit immigration from Africa, to insure that no one with AIDS enters this country?

* Do wealthy countries, such as the U.S. and those in Western Europe, have an obligation to help fund AIDS drug programs in Africa?

CLASSROOM STRATEGIES

Before Reading: Tell students there is no cure for AIDS. Drugs can prolong life by helping the immune system fight infection, but there is no way to rid the body of HIV or remove AIDS once it has developed.

Critical Thinking: Discuss the shame that prevented many African countries from dealing effectively with AIDS. (South African President Thabo Mbeki long denied that HIV caused AIDS.) Is shame about sex unique to Africa? Africa's experience might serve as a lesson to U.S. teens, who often are ashamed to seek treatment when they roar they have been exposed to a sexually transmitted disease--or who may even be pregnant. Use Africa's example to illustrate how denial can lead to disaster.

Note that even with a steep cut in drug prices, the six countries that have struck a deal with drug companies can treat only 1 or 2 percent of their infected citizens. What criteria should officials employ when deciding whom to treat? Should they focus on children? The educated? Skilled Workers? (The likelihood is that treatment will go to city dwellers and those who live near hospitals.) Debates: (1) Note the view of world health officials that Africa can't be saved unless wealthy countries help pay the bill for treating AIDS victims. Should the U.S. undertake a massive' effort to deliver AIDS treatment to affected Africans--though they live far beyond our borders? (2) Of 13.2 million children worldwide who have been orphaned by AIDS, 12.1 million live in sub-Saharan Africa. Should the U.S. pay to care for such orphans?

Josephina, 35, works seven days a week as a maid in Johannesburg, South Africa. She earns about $100 a month, which must support her, her husband, Thomas, who has no job, and her three children, ages 8, 10, and 14.

Josephina is also HIV-positive and will no doubt die of AIDS. She believes she was infected by her husband, who has had many girlfriends. On her salary, she cannot afford the combination of drugs known as the "triple-therapy drug cocktail" that has meant longer lives for many Americans with AIDS. The drugs and tests that go with them cost more than $10,000 a year.

But Josephina has a greater worry. It is not only she and her husband who have the disease. Two of her children, the youngest and oldest, do too. Presumably, they were infected before they were born. She has not told them yet. She does not know how.

"I am going to wait a little while longer," she says. "They are too young to hear they will die."

Families like Josephina's are the long, sad face of AIDS in Africa.

Some 17 million Africans have died from AIDS, making it the worst plague since the Black Death killed 25 million people in Europe in the 14th century. Another 26 million Africans are infected with HIV, the virus that causes AIDS, and the vast majority cannot afford the drugs that might save their lives.

But that could change. Earlier this year, as pressure mounted on governments and pharmaceutical companies to make the drugs more accessible, something remarkable happened: The major American and European drug companies began to make deep cuts in drug prices. In an epic story of tragedy and despair, there is now a glimmer of hope.

"I think, really, things are changing," says Awa-Marie Coll-Seck, head of research and policy for UNAIDS, the United Nations agency fighting the disease. "If we could get the reduction to $100 a year, we can hope that the majority could get it."

THE HIDDEN DISEASE

AIDS almost certainly originated in Africa, from a chimpanzee virus that passed, probably in the 1950s, to humans in Central Africa who hunt and eat chimps. The disease spread around the globe, but wasn't recognized until the early 1980s. In the U.S., health authorities were quick to make the blood supply safe, and to get out the sometimes-controversial message that condoms and clean needles stop the transmission of the disease.

But Africa was paralyzed by denial. The shame and social stigma associated with a sexually transmitted disease kept it hidden. Some African leaders denied that their countries had any ADS cases, and most countries did nothing while the disease ravaged their populations.

Today, denial is no longer possible. In 16 sub-Saharan countries, at least 1 in 10 adults is infected with HIV. Some countries could lose almost a third of their population. Unlike the U.S., where AIDS affects mainly adults, Africa is losing children and teenagers to the disease. Each week, dozens of newborn babies become infected, either from their mothers' blood or from breast-feeding because their mothers cannot get drugs that prevent mother-child transmission. In South Africa, where a 15-year-old has a better than even chance of dying from AIDS, many young girls become infected because of a popular rumor, one that the government cannot seem to stamp out, that a man can cure his AIDS by having sex with a virgin.

Across the continent, AIDS has robbed schools of their teachers, hospitals of their doctors and nurses, and children of their parents. Until recently, orphanages had been relatively rare, because in Africa families take in the children of relatives. But AIDS has created some 12 million orphans. Orphanages have sprung up everywhere, and in rural villages, one can find huts where one big sister or one grandmother is trying to find food for 10 or more children. On a poor continent, the disease is overwhelming family love.

AVERTING TOTAL RUIN

At this stage of the epidemic, health authorities say preventing new cases--by distributing condoms, for example--is not enough. In order to spare the continent from complete collapse, something must be done for the millions already infected. But in a region where most people live on less than $2 a day, drugs that cost more than $10,000 a year are not an option. Of the 26 million HIV-infected Africans, only 10,000 have access to the drugs.

For years, as international pressure mounted to make treatment more affordable where it is most needed, the European and American drug makers that hold the patents on AIDS drugs were reluctant to lower prices. In 1997, South Africa passed a law allowing the country to import cheaper generic drugs, even if it violated patent law. In response, 39 drug companies filed suit to overturn the law and protect their patents. And the U.S. threatened to impose trade sanctions against South Africa if the country flouted U.S. patents.

The companies were concerned about threats to their intellectual property rights. Patents enable drug companies to market their products, free from generic competition, for 20 years. During that time they can set prices as they see fit; that freedom, they say, enables them to recoup the high cost of research and development, and to invest in developing new and better medicines.

"We object to the premise that intellectual property rights are a barrier to access to good medicine," says Shannon Herzfeld, a spokeswoman for the Pharmaceutical Research and Manufacturers of America. "Anyone who says, `We have to steal,' is wrong. Stealing ideas is not how one provides good health care."

But protests around the world embarrassed the Clinton administration into dropping the U.S. threats in 1999. Earlier this year, an Indian company, Cipla Ltd., offered to sell its generic version of the drug cocktail to Africa for $600 per patient per year. Almost immediately, the big drug companies began cutting their prices to match Cipla's--partly to protect their patents. And in April, bowing to public pressure, the companies withdrew their lawsuit in South Africa.

"This is not about profits and patents," says John L. McGoldrick, executive vice president of Bristol-Myers. "It's about poverty and a devastating disease. We seek no profits on AIDS drugs in Africa, and we will not let our patents be an obstacle."

DEEP DISCOUNT NOT ENOUGH

By late April, six African countries had struck deals with major Western drug makers to provide treatment at a couple of dollars a day per patient. But even at these prices, the six countries expect to be able to provide the drugs for only 1 or 2 percent of their HIV-infected patients.

No African country has the resources to pay for the drugs for everyone who needs them. Even in South Africa, the continent's richest country and the one with the most developed health-care system, buying drugs at $600 a person would eat up all the money the government now budgets for all drugs--including those for heart disease, cancer, malaria, and tuberculosis, antibiotics, and other medicines that save millions of lives each year. And that doesn't include the cost of laboratory tests or of training doctors and nurses. Plus, the AIDS drugs don't cure the disease; they help the body fight off infections. Treating those infections could still be very costly.

World health officials say Africa can't be saved unless drug prices go even lower, and rich countries in North America and Europe help pay the bill. "While affordable prices are important, actually getting drugs to the people who need them in the poorest countries will require a major financing effort," says Adrian Otten, a senior official at the World Trade Organization.

Until then, AIDS remains a death sentence for people like Josephina and her children. "I don't know if I feel worse about being the angel of their death, or that they might live after I am gone," she says. "I have nobody to look after them, and they are so young."

Mapping Despair

Of the 36 million people infected with HIV, 26 million live in sub-Saharan in Africa. In 16 countries in the region, at least 1 of every 10 adults is infected. Here's the breakdwown.

[ILLUSTRATION OMITTED]

GLOBAL OUTBREAK

Numbe of people infected with the AIDS virus,
by region

SUB-SAHARAN AFRICA           26 MILLION
SOUTH & SOUTHEAST ASIA       5.8 MILLION
NORTH AMERICA                920,000
WESTERN EUROPE               540,000

SOURCE: UNAIDS, DATA IS MOST RECENT AVAILABLE, MAP
DATA FROM 1999; GRAPH DATA FROM DECEMBER 2000, EXCEPT
FOR AFRICA, WHICH IS FROM APRIL 2001.

Note: Table made from a bar graph.

DONALD G. MCNEIL JR. is a foreign correspondent for The New York Times, based in Paris. With reporting by Peta Krost in South Africa.