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HIV fight comes up short in Nigeria

Drugs running out at public clinics

JOS, Nigeria -- Kenang Choji, a 33-year-old shopkeeper and mother of two, is infected with HIV. But she was supposed to be one of the fortunate in Africa. She lives in Nigeria, one of the few countries on the continent that have been providing life-extending AIDS drugs to those who need them.

But as she rested on a bench in a treatment center in Jos one recent day, she heard the awful news: The drugs had run out. Nigeria had announced with great fanfare in 2001 that it would provide antiretroviral drugs for 10,000 people, but officials say that only a year's worth of drugs was purchased -- and no one is sure when the next shipment will arrive, or who will pay for it.

Today is World AIDS Day, when countries and organizations take stock of their efforts to fight what is predicted to be the deadliest epidemic ever. Many will speak of beating back the threat: The World Health Organization is announcing a strategy for treating 3 million people with the AIDS drugs by 2005, and senior US officials led by Health and Human Services Secretary Tommy Thompson are on their way to Zambia, carrying a message that help is coming.

But the reality in Africa shows there are no easy fixes. UNAIDS estimated last week that only 75,000 Africans were receiving antiretroviral drugs, or 2 percent of those who need them. Subtract the Nigerians, and the number falls to 65,000. Several Nigerians who had been receiving treatment said last week that they would try to find enough money to buy the drugs on the private market, or they would simply go without treatment.

The issue is critical: Since antiretroviral drug treatment must be taken every day for life, AIDS specialists warn that any break in treatment could lead to resistance to the drugs. That means the virus can mutate and eventually become untreatable with those drugs.

"Many African countries are going to have these problems because of the sheer numbers of people crying out to be treated," said Dr. John Idoko, chief medical consultant for Nigeria's AIDS treatment plan. "If we have a problem with 10,000, consider what will happen with 100,000, or 200,000."

The drugs began running out two weeks ago in nearly all treatment centers around the country.

At Idoko's center in Jos, a city of 2 million people on Nigeria's central plateau, more than 200 patients arrived for their medicine one day last month. They were told that the government's drugs were gone.

The treatment had cost the patients 1,000 naira, or about $7, a month. Idoko's clinic offered drugs for 14,000 naira, or roughly $93 a month -- a cut rate from the lowest generic prices on the market of about $300 a month, but still too expensive for most.

"I don't know what to do," Choji said in a hoarse whisper, her head resting on the bench. "My body feels so weak. My body is just burning. They say the price is 14,000, but I don't know where to find 14,000."

With great effort she sat up, but then buried her head in her hands.

Outside the clinic, small groups of HIV patients walked around as though in a daze. "I must say I'm a little bit angry, or disappointed," said Esther Filndon, 40, who traveled nearly four hours by bus from Abuja, Nigeria's capital, to collect the drugs. "I've been on the drugs for seven months. Now, I'm unsure what to do. Maybe if I change my diet, that will sustain me for a few months."

Others spoke about how the antiretroviral drugs had restored their health. Without hesitation, they rattled off their CD4 counts, which take stock of a person's immune system and help gauge the ability to fight off infections; medical guidelines recommend antiretroviral drugs for anyone with a CD4 count below 200.

"It's not just disappointing. It's losing the hope we have," said Tokkes Clement Bankat, chairman of Hope Support Group, which consists of 209 HIV-positive members who meet monthly. "It's the hope that really sustains us."

Several patients saw Idoko walk into the clinic, and they surrounded him, asking his advice.

"We are sorry," he said. "It's not our fault. If you have a little money in your pocket, why don't you buy from here? For a few months? Then you are sure you will stay well."

But Idoko later said he could not promise when the drugs would be available. He also said that because the drugs sat in a storeroom for months before the clinics were ready, some batches of nevirapine -- one of three antiretroviral drugs used in Nigeria -- had expired. He threw those out.

Idoko and other health officials in Abuja, the capital, said President Olusegun Obasanjo has approved $3.5 million in emergency spending to buy another one-year supply of antiretroviral drugs for 10,000 people. But the disbursement order has sat for several weeks in the Finance Ministry, one in a tall pile of such orders going unfulfilled because the government said it does not have the money on hand, the officials said.

Mohammed Farouk, an AIDS activist and a member of Nigeria's coordinating committee for the Global Fund to Fight AIDS, Tuberculosis, and Malaria, said the country may turn to the Global Fund for emergency financing. The fund initially had approved this year $3.5 million for AIDS treatment but has not turned over the money because of questions about the procurement plan, according to Nigerian officials.

Asked whether the Global Fund would release emergency funds to buy the drugs, Duncan Earle, the fund's portfolio manager for Africa, said in a telephone interview from Geneva, "We would definitely consider it internally, and we would explore it with our Nigeria colleagues."

But even if the fund releases the money soon, Nigerian officials expect that it may take three to six months to get the new supply of antiretrovirals to clinics. That delay puts an unknown number of lives at risk even as doctors have battled to gain ground against AIDS in Nigeria.

"We're working hard," Idoko said. "But one of the biggest issues is sustainability. We need to get the drugs. They are very unforgiving if you stop taking them for a while. It's very worrying for us, and for the whole AIDS program. Without the drugs, people are going to start to fail, and they will die."

The problem has obscured several major strides made recently in the country, resulting from a partnership called the AIDS Prevention Initiative in Nigeria, which links the government, the Bill & Melinda Gates Foundation, and the Harvard School of Public Health. Harvard has used a $25 million grant from the foundation to start four centers in Nigeria for AIDS treatment and prevention, while also helping more than a dozen other clinics or laboratories. Perhaps the most advanced site, officials in Nigeria say, is Idoko's clinic in Jos.

The Jos program has a state-of-the-art laboratory and a prevention program to interrupt mother-to-child transmission of HIV, and provides antiretroviral treatment for more than 800 people, up from a few dozen two years ago. Idoko separately runs a nonprofit group called Halt AIDS Now, which sends workers into local beer halls carrying hundreds of condoms, and holds AIDS education classes promoting abstinence and safe sex among young men and women.

In Gada-Biyu, a community of 15,000 people who live in shacks near the center of Jos, hundreds of men and women relaxed in adjoining one-room hovels on a recent Sunday to drink a locally brewed, grayish beer called burukutu. They gulped from calabash bowls and howled in pleasure. Outside, vendors grilled pork and dog meat over coals.

Temitayo Apena, a program officer at Halt AIDS Now, walked easily among the drinkers and then ducked into a school, where about 25 young women listened about how to protect themselves from AIDS. One woman said she has a friend whose boyfriend wants the couple to have sex.

Apena jumped in. "Sex is not a way of satisfying your boyfriend," he said. "There are other ways of sharing love. You can show love by caring."

He then broke into song: "If you love me, you'll wait for me."

Across town, at the HIV clinic, women waited anxiously for counselors to call them into private rooms for their test results.

Hasana Suleiman, 20, eight months pregnant with her first child, listened to Esther Efe tell her about the test. Then Efe broke the news: "You're negative," she said.

Suleiman smiled, and exhaled. "I was nervous," she said.

John Donnelly can be reached at donnelly@globe.com.

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