A pandemic fueled by poverty

Do you think it's premature to discuss issues like compulsory licensing for generic anti-retrovirals?

The anti-retrovirals have made a huge impact in the West. We're not against them. But one of the problems we have is that they're still hugely expensive. I know they've come down dramatically in price.

But what about CIPLA and other companies proposing to offer these drugs for as little as $1 a day?

It still takes them out of the reach of 99 percent of the kind of people I work with in Africa. They need to come down even further in price for them to be effective.

We know that people infected with HIV/AIDS can lead lives of good quality if they have access to food, to clean water, to the simple drugs for opportunistic infections. They can live long enough to see their children grow up, to educate their fellow workers so that their skills can be passed on to the next generation.

We would estimate that if we could have access to the things we're talking about you could increase life expectancy of those with HIV/AIDS by eight years -- which is enough time for their kids to grow up enough to be self-sufficient. We're having to teach life skills to some of the orphans we're looking after now. We're having to teach them how to do simple agriculture and simple household tasks. Simple parenting skills because they've never been parented; their parents died when they were so young.

There are many aspects about using anti-retrovirals that worry me. Many countries in Africa do not have the infrastructure -- and it's true. The critics have a strong case here. One has to look at why the healthcare systems are so weak, and you have to look at the impact of structural adjustment [debt repayments] on Africa. For the last two decades, health and education has suffered. I've personally witnessed this as health budgets have been slashed and user fees have been introduced. You have to wonder whether it's the policies of the International Monetary Fund and the World Bank that have actually exacerbated the situation we're in now.

Many countries don't have the infrastructure, but it also has to be said that there are some places that do. It exists in the larger cities and some of the missionary hospitals, which are very sophisticated. They could handle anti-retroviral drugs. In those cases, perhaps they should have access to them. But you have to be very careful with these systems.

What could go wrong if the system is not in place?

We've seen with the tuberculosis system that even when we had what we think are good structures, we've had huge problems with patient compliance. People think after two months they're better and stop coming to pick up the drugs, particularly if they have to pay for them. The idea of lifetime drugs is a very big issue for Africans. Or perhaps when you feel better, you'll give the drugs to your neighbor who can't afford them. That could create new strains. We've had huge problems in Africa with multiresistant TB.

There are arguments for and against on this one, but we need to find a line in between. But probably in the majority of situations, it will not be feasible. But you should not be writing off Africa just because you can't use anti-retroviral drugs. There's evidence that if you can get basic necessities to them -- water, food and simple treatments -- we can expand quality and duration of life.

We should also be using AZT and nevirapine to stop transmission from mother to child. But that doesn't take care of the mother. We need to create a package for mother and child that will allow the mother to live long enough to take care of the child during the first years of its life.

UNAIDS estimates that there are 13 million AIDS orphans -- roughly as many as there are children in the United Kingdom. Some of these children are very vulnerable. They become heads of households at the age of 10; many of them have been orphaned two or three times. They've lost their parents, their aunts and uncles, their grandparents. There's a small group of very traumatized children out there -- we're concerned about their winding up on the streets and getting infected.

Your prescription for fixing the problem sounds more like poverty relief than AIDS relief.

We need to rebuild the infrastructure and support these communities. There's already tremendous strength there. We're calling for debt relief, fairer trading laws. But we're also calling for member nations of the Organization for Economic Cooperation and Development to honor the pledge they made 30 years ago to give 0.7 percent of their gross domestic product for overseas aid. As we know, most of them got nowhere near this. The U.S. is at 0.1.

Now, in this time of AIDS, which is on a scale we haven't seen before, there's a new dynamism to arguments about giving this money. We've calculated the total figure at $100 billion, which would allow us to rebuild the health infrastructure and the education infrastructure. We could target a lot of money into communities for orphans and the vulnerable. That scale of money is what you really need if you're going to be serious about tackling AIDS.

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