Aids Alert International-AIDS epidemic in Africa threatens security worldwide

President Clinton's recent announcement shows depth of catastrophe

It's no coincidence that an increasing number of media reports on AIDS this year have focused on the epidemic's effects in Africa. The spread of HIV among southern African nations has reached such gigantic proportions that it's impossible to ignore, HIV experts say.

The World Health Organization (WHO) in Geneva, Switzerland, announced in June that the average life span in southern Africa has been reduced by 15 to 20 years because of AIDS.

"What you have happening in a lot of these countries is between 10% and 40% of your population of reproductive age is infected with HIV, and it will take a devastating health toll," says Eve Lackritz, MD, assistant chief for science in the international activities branch of the Division of HIV/AIDS Prevention for the Centers for Disease Control and Prevention in Atlanta.

Threat to development imperils security

"This erodes the entire infrastructure, obliterates it, and affects every component of your society, so that would include education, government, health, and development — and it's that threat to development that makes this a security threat," Lackritz says.

In some African nations, as much as 70% of military personnel are infected with HIV. Also, as many as 90% of those infected with HIV may not know they are infected and therefore are continually spreading the virus, says Jacob Gayle, PhD, senior technical advisor and The Joint United Nations Programme on HIV/AIDS (UNAIDS) secretary in Washington, DC.

"Any epidemic like this that predominantly hits the prime work force and prime reproductive force has some serious consequences," Gayle says.

Also, organizers of the XIII International AIDS Conference chose Durban, South Africa, to host the nearly 10,000 delegates who were expected to attend this year's conference in July. Organizers saw the Durban conference as an opportunity to focus attention where the effects of the epidemic are being felt the most.

In May, the White House announced that the Clinton administration was viewing Africa's AIDS epidemic as a threat to the national security of the United States. Unstable nations that are experiencing the sort of economic insecurity that AIDS is creating in parts of Africa are vulnerable to political strife, coups d'etat, and economic upheavals, the administration said.

Impact of disease far-reaching

President Clinton has continued to emphasize the importance of focusing on the African AIDS problem. For instance, in a May 30 speech at the Pavilion of Knowledge Science Center in Lisbon, Portugal, Clinton said: "In Africa, Asia, and many parts of the world, diseases like AIDS, malaria, and tuberculosis are killing not only people, but hope for progress. In Africa, where 70% of all the world's AIDS cases exist in sub-Saharan Africa, some countries are hiring two employees for every job on the assumption that one of them will die of AIDS."

Clinton also remarked to the scientific community in Lisbon: "In other African countries, 30% of the soldiers have the virus. Millions suffer from strains of malaria that are increasingly resistant to any drug. And a third of the world has actually been exposed to tuberculosis. These diseases can ruin economies and threaten the very survival of societies."

Despite criticism from Senate Majority Leader Trent Lott (R-MS) that Clinton was pandering to special interest groups by focusing on the African AIDS problem, many international organizations and experts agree that the epidemic's impact on sub-Saharan Africa has become an international crisis. And as a senior administration official points out, the Clinton administration has been concerned about the AIDS epidemic in Africa for years. Focusing on it as a national security threat doesn't mean the U.S. will ignore other security threats, such as terrorist activity, rogue states, and other international problems, but it will mean that in the 21st century, the United States is expanding its view of what constitutes a national security threat, the official said.

The WHO and UNAIDS have promoted a greater focus on the epidemic, calling it Africa's top human security issue. UNAIDS says the disease kills 10 times more people in Africa than does war. About half of Africa's HIV infections occur in people below the age of 25, killing many before they are 35 years old.

"AIDS doesn't just affect the health sector; it affects every sector because of the impact on the working populace," Lackritz says.

While the problem is as obvious as a plane wing sticking out of a building's roof, solutions are elusive. United States AIDS activists may believe all it will take is cheaper antiretroviral drugs, but those who have worked in Africa or visited African hospitals say cheaper AIDS drugs will not stop the epidemic by themselves.

Experts focus on prophylaxis

"The problem is not only to have the drugs in the country, but mainly to use these drugs properly," says Badara Samb, MD, PhD, UNAIDS care advisor in Geneva.

Rather than focusing on affordable antiretrovirals, a better approach is to focus on building the developing nations' health care infrastructure and providing prophylactic medications for opportunistic infections (OIs), Samb and Lackritz say.

"Prophylactics would reduce the mortality of HIV/AIDS and improve the quality of life, and they're very cheap, with the price for one year of prophylactics being maybe as low as $8," Samb says.

"In Africa, there are many bacterial diseases, and those are the main killers of people with HIV," he adds.

Lackritz says the poorer African nations are missing too much infrastructure capacity to be able to deal with antiretroviral distribution.

"The wards are overcrowded with patients with wasting disease, TB, and diarrhea, and the mortality rates are very high," Lackritz says. "Getting hospitalized in that setting is a very poor prognosticator and tends to be a terminal event for many patients."

The first priority should be to help these nations boost their health care infrastructure to ensure accountability and procurement of central drugs and to make an impact in treatment of sexually transmitted diseases, experts say. Then there should be a focus on providing basic prophylactics, such as trimethoprim-sulfamethoxazole (co-trimoxazole). This inexpensive antibiotic is effective against some of the most common OIs, including pneumonias, non-typhoid salmonella, and enteric pathogens.

"Co-trimoxazole should be readily available and very cheap, but the health care delivery system has to be put into place," Lackritz says.

Then, there needs to be increased education of health care providers on what AIDS-defining illnesses are and which drugs are used for treatment and prevention. And finally, there will need to be a strengthening of lab capacity to diagnose opportunistic infections, including increasing the capacity to do X-rays and simple culturing of blood, stools, and sputum, she adds.

"So it's a three-tiered approach, and we can't deliver antiretrovirals without a drug delivery system, and that just doesn't exist in a lot of places," Lackritz says.

Lackritz was involved with a trimethoprim-sulfamethoxazole prophylaxis study that found that administration of the drug in HIV-1-infected patients with tuberculosis significantly decreased mortality and hospital admission rates. The study also found significantly fewer admissions for septicemia and enteritis in the co-trimoxazole group.1 Co-trimoxazole also can be used to treat salmonellosis, isopsoriasis, cerebral toxoplasmosis, and bacterial pneumonia.

UNAIDS promotes prophylaxis in Africa

Both the CDC and UNAIDS are working on programs to help boost the African health care infrastructure.

"UNAIDS promoted the use of prophylaxis, as well as access to antiretrovirals, even though the prices still are too high," Samb says.

The CDC will receive some $35 million this year for AIDS programs in Africa and India. President Clinton is asking Congress for $325 million to fight international AIDS, which more than doubles the nation's previous two-year commitment. The administration also has committed more than $70 million for TB prevention, control, and research and more than $100 million to combat the spread of malaria. (See story on the U.S. - European Union agreement to fight HIV, p. 4.)

UNAIDS announced in May that the organization had begun to work with five major pharmaceutical companies on ways to accelerate and improve the provision of HIV/AIDS care and treatment in developing countries. These companies are Boehringer Ingelheim, Bristol-Myers Squibb, Glaxo Wellcome, Merck & Co., and F. Hoffmann-La Roche.

Reference

1. Wiktor SZ, Sassan-Morokro M, Grant AD, et al. Efficacy of trimethoprim-sulfamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Cote d'Ivoire: A randomised controlled trial. Lancet 1999; 353:1,469-1,475.