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BRUCE D. WALKER AND WILLIAM R. RODRIGUEZ

Bold plan to treat AIDS in S. Africa

PRESIDENT THABO Mbeke and the South African government exercised bold leadership this week in the fight against HIV/AIDS on a continent ravaged by this virus. The Cabinet's decision to provide life-saving treatment using antiretroviral therapy to all South Africans in need means countless lives can be extended and families preserved, and it provides the opportunity to demonstrate that effective HIV treatment can be provided on a large scale in poor settings.

The plan, set forth by a South African National Task Team, represents an enormous logistical task -- to make anti-HIV medicines available in each of 53 health districts within the next year, and to treat up to a million and a half persons by 2008. No program of this magnitude has ever been implemented. Can such a program requiring complex medications possibly work in a country where health resources are limited and a large percentage of infected persons live in poverty?

On an individual level, the answer is an unequivocal yes. The story of Zinhle Tabethe is illustrative of our experience in Africa. Infected with HIV, her crippled immune system was losing the battle against tuberculosis, meningitis, and pneumonia. Eighteen months ago she was bedridden at her home in KwaZulu Natal, without running water or electricity, unable to pay for medications.

Although Zinhle and her family had already accepted that she would die, as more than 17 million since the start of the AIDS epidemic, a friend made a last, desperate attempt to intervene and secured a precious slot for Zinhle in a small trial investigating the use of anti-HIV drugs in impoverished settings like KwaZulu Natal.

Within weeks of starting the three-drug combination, Zinhle's infections began to clear; she started to regain weight and ultimately returned to work to support her family. She is now healthy and works as an HIV outreach worker, teaching uninfected persons how to avoid the virus and infected persons how to take the life-saving medications.

Since starting treatment, she has not missed a single dose, and the level of virus in her body is so low that tests cannot detect it -- clear evidence of success.

On a national scale, the challenges to provide such treatment to all in need are large. Over 5 million of South Africa's 45 million citizens are believed to be infected with HIV, and 400,000 are expected to need treatment imminently. An equity clause in South Africa's post-apartheid constitution requires making health benefits available to all citizens, equally and simultaneously.

The South African government has firmly committed to this and will fund the HIV program as part of national health care. The program has been carefully planned and is impressive in its attention to detail.

Success and sustainability will require a coordinated effort to train health care workers in the nuances of HIV treatment and a major infusion of human resources -- doctors, nurses, pharmacists, counselors, laboratory technicians -- as well as new clinics, new laboratories, and effective systems to manage the effort.

The William J. Clinton Foundation, which served a critical advisory role to the South African Task Team, has committed to coordinate support from outside sources anxious to help.

We have had the opportunity to assist in this effort, and additional HIV treatment expertise will be needed in the early stages of implementation to augment the excellent but small cadre of South African health care workers who have begun treating this disease.

The Clinton Foundation is also assisting the South African government to obtain the lowest possible prices for drugs and test kits, and to develop effective program management to ensure that patients receive their life-saving medications safely and without interruption.

Of course, South Africa will continue to support AIDS prevention. But through this enlightened decision, the government seeks to make Zinhle's story of successful treatment commonplace.

South Africa has the opportunity to become a world leader in treatment of HIV infection and to create knowledge about how best to administer treatment in poor settings that will provide critical information to other countries struggling to develop similar programs. This bold step forward should receive our strongest support.

Dr. Bruce D. Walker is director of the Division of AIDS at Harvard Medical School. Dr. William R. Rodriguez is director of the Division's Office of International Programs.

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