The Chasm in Care - HIV infection is rampant in developing countries - includes related article

IN THE UNITED STATES, AIDS deaths dropped 47 percent from 1996 to 1997--thanks mostly to expensive drug treatments. Though such therapies have reduced AIDS fatalities in the United States and Western Europe, elsewhere the picture is almost uniformly bleak. Rates of HIV infection are soaring in impoverished African and Asian countries--the nations least prepared to prevent and treat the disease.

More than 30 million people are now infected with HIV, and almost 90 percent of them live in the developing countries of Asia and sub-Saharan Africa. Worldwide, 16,000 people are newly infected with the virus every day--a figure twice as large as previous estimates, which were modeled in part on the infection rate in Uganda, where the epidemic has recently begun to plateau. In some countries, the extent of infection is nothing short of horrifying. In Zimbabwe, for example, one-quarter of the adult population is now thought to be infected with HIV. But the ravages are not limited to Africa. India, with 4 million cases, is now the world leader in absolute numbers. Infection rates are also rising with blinding speed in Ukraine, a country that was largely free of HIV before the 1991 breakup of the Soviet Union. It now has 110,000 people infected with HIV. That is nearly four times as many as in all of Eastern Europe just four years ago.

Poor countries can't afford expensive drugs to treat the disease. But last year brought a bit of good news. In February the Centers for Disease Control and Prevention announced that a short, four-week course of the anti-AIDS drug AZT during late pregnancy and delivery halved the transmission rate of the virus from HIV-positive women to their babies. The trial had been heavily criticized as unethical because half its subjects--pregnant HIV-positive women in Thailand and the Ivory Coast--were given a placebo, despite results from a 1994 study showing that the drug reduced maternal HIV transmission. Still, the CDC persisted, noting that the 26-week treatment the earlier study tested costs $800--roughly 80 times the annual health budget per person in many poor, developing countries. Only a second trial could test whether a shorter, less expensive course of drug treatment could work, too.

When positive results came from Thailand last February, the trial was halted, and the Ivory Coast women on the placebo were switched to the drug. But even the cost of the short, four-week course of AZT--$50--is far beyond the reach of many women in developing countries. The good news is that the Joint United Nations Program on HIV/AIDS, based in Geneva, agreed to pay for the treatment of 30,000 HIV-positive pregnant women in 11 developing countries. Glaxo Welcome, the maker of AZT, will supply the drug at a 60 to 75 percent discount.

Though the United States can generally afford such preventive strategies, there are still substantial gaps. For example, 40 percent of all U.S. AIDS cases occur among injecting drug abusers, and the majority of pediatric AIDS cases occur among children born to injecting drug users or their partners. Yet despite results from a recent government inquiry demonstrating that needle-exchange programs can reduce HIV transmission among injecting drug users by 30 percent, the Clinton administration in April refused to lift a ban on federal funding for such programs, stating that the programs send the wrong message to children.

This past year also saw new findings illuminating the early history of the AIDS virus. In February, researchers led by David Ho of the Aaron Diamond AIDS Research Center in New York announced that they had isolated fragments of the HIV genome from a blood sample drawn in 1959 from a man living in what was then Leopoldville, Belgian Congo (now Kinshasa in the Democratic Republic of Congo). By comparing genetic sequences of these segments with sequences from more recent strains of HIV, they created a family tree and traced elements in the 1959 sample to a common ancestor of three present-day HIV subtypes. The 1959 virus, it turned out, closely resembles the ancestral virus, which is believed to have hopped from an animal host into humans. Based on that resemblance, the researchers suspect the hop probably occurred in the early 1950s or mid-1940s--soon after the end of World War II and the collapse of European colonialism in Africa.

The timing of those events supports the observation that the spread of HIV accelerates in conditions of social turmoil and poverty. Simon Wain-Hobson, a British virologist and AIDS researcher at the Pasteur Institute in Paris, believes that the disruption and migration that characterized post-colonial Africa may have played a key role in the spread of HIV. "The English and the French kept people ruthlessly under control," says Wain-Hobson. "They didn't let them move; they didn't let them travel. And what happened finally when the English pulled out was a free-for-all. There were pogroms, there was corruption, there was blackmail, there were movements of populations, the introduction of the motorcar. There was the beginning of the urbanization of Africa, which is a postwar event." These developments, he believes, may have helped HIV expand beyond the narrow range it occupied after it first emerged. "It's a plausible hypothesis," says Wain-Hobson, "but we might never get beyond that."