Top: AIDS patient in Homa Bay Hospital, Kenya
Bottom: AIDS prevention poster, Malawi
(Both photos © Tom Stoddart/IPG 2001)
"A few months ago, I was watching my body waste away from infections. I couldn't walk anymore, I had to stop working, and I became a burden on my family. Finally, I was hospitalized. I was feeling really desperate at that time. But recently, I began antiretroviral therapy, and I feel like I have slowly begun to regain life! The diarrhea and fever have disappeared, and I have begun some physiotherapy. I have gained 20 kilograms! I've been able to go back home to my family, and now I can come to the hospital for my visits walking on my own two feet. I talk a lot about my illness with a supporter from the hospital who comes to visit me and who helps my mother to care for me."
— Pierre, a 30-year old HIV-positive man
Pierre is a patient at the MSF/PRESICA HIV clinic in Yaoundé, the capital of Cameroon. Since January 2001, Doctors Without Borders/Médecins Sans Frontières (MSF) has been running a pilot project providing antiretroviral (ARV) therapy to people living with AIDS. Pierre is one of the lucky few to receive this treatment, and he is beating the odds. Day by day, his improved condition dispels the myth that ARV treatment for HIV/AIDS is impossible in this part of the world.
"The thing we hear most often from our patients is that they feel better," says Laura Ciaffi, M.D., head of the MSF project in Cameroon. "Of course, it is very early in the process, and we still have to run viral-load tests to see how effective the treatment is. But when we look at someone like Pierre, we know it is working and we know he is taking his pills."
In Cameroon, a country of 14 million people and a per capita GNP of $620, the latest estimates put the HIV prevalence rate at 10 percent. The epidemic has orphaned 270,000 children. As in many developing countries struggling against AIDS, the need to expand care for HIV-positive people is urgent.
MSF's antiretroviral program is run out of the HIV clinic in Yaoundé's largest public hospital. It is a seven-year project, in partnership with the Institut de Recherche et Développement of France, which is following 362 patients, 150 of whom are expected to need ARV therapy during the period. The patients are charged a one-time fee of roughly $35, which covers all drugs and lab tests for five years. The fees are put into a "solidarity fund," which can later be used to provide economic support to patients if needed.
One of the project's goals is to answer many questions about how best to provide treatment for AIDS in a resource-poor setting. Through this project, researchers will try to simplify treatment protocols, develop patient follow-up programs, and determine the minimum level of lab tests necessary to monitor patients safely. Patients are started on ARV therapy based on a number of medical criteria, including CD4 cell count (an indicator of the state of the immune system) and clinical indicators. This hospital is the only one in Cameroon equipped to run the viral-load tests used to determine how well the treatment is working.
The team working in the HIV clinic here has witnessed the impact the falling prices of ARVs are having in Yaoundé. Not only are the drugs becoming affordable to more people, but the mere possibility of treatment is offering hope to patients who previously had none. In March 2001, Cameroon finished negotiations with five proprietary drug companies to reduce the cost of a triple-combination of antiretrovirals to around $1000 per year. More recently, the government has bought 1500 treatment courses for $350 per year from a generic drug manufacturer in India. In January, the MSF clinic had an average of seven patients per day. After discounted drugs began to arrive in Yaoundé, this number increased to 20-30 per day.
"People now realize that we can do something for them, that AIDS does not have to mean an immediate death sentence," said Dr. Ciaffi. "We are prescribing antiretrovirals for more and more patients. However, many of them do not come for the antiretrovirals-they come to get tested, to receive care for their opportunistic infections, or to be treated for other diseases like malaria. But because people know that treatment for AIDS is now possible, they are changing their attitude and coming to our HIV clinic."
The possibility of treatment is also eroding the wall of social stigma surrounding the disease. Still, the stigma associated with being HIV-positive remains strong in Cameroon. "In Cameroon, if you have HIV, you are already dead in the minds of others," Dr. Ciaffi explained. "Many people don't realize that, even without therapy, people with HIV can live for ten years or longer. Families are often unwilling to invest in health care for people who they think will just die-even if it is just to pay for treatment for opportunistic infections or other diseases. Having ARV drugs available may transform the stigma around HIV into something more accepted, like diabetes or hypertension. To me, the stigma has as much to do with the idea of death as it has to do with sexuality or morality. By bringing back the possibility of life and a future, I think treatment will break the cycle of HIV denial, infection, and death."
"But are the drugs everything? Of course not," Dr. Ciaffi continues. "Are AIDS patients still dying? Of course-by the thousands. But the availability of drugs is having an impact far beyond the relatively few people who are actually receiving them. We have to continue to insist on the principle that medical treatment for AIDS should be provided, even when we cannot do it for everyone and we cannot do it for everyone tomorrow. The principle makes all the difference."
Despite these challenges, Dr. Ciaffi remains committed. "Five years ago, when I was an AIDS doctor in Italy, the first really effective antiretroviral combinations were becoming available in Europe. I recently went back to visit my old clinic in Milan, and I was so happy-but surprised-to meet many of my old patients. They were supposed to have died of AIDS years ago. One day, perhaps five years from now, I hope to come back to Cameroon to see the same thing."