Sir, Every word of Austen Ivereigh's article on fighting Aids in Africa (The Tablet, 15 December) rings true to those who know the problems he so Vividly describes. But the difficulties of initiating and sustaining treatment for the millions who are infected with HIV, as the article thinks possible, are truly horrendous, and extend far beyond the availability of cheap and effective drugs. Anti-retroviral therapy must be administered daily, over years, and its side-effects managed. There is also the all-important need to avoid creating drug-resistant strains.

There are very few health systems in sub-Saharan Africa that could possibly take on this extra work, burdened as they are by their own loss of staff through Aids. There are, also, the difficulties in discovering who is infected and who is not, so vividly illustrated by the denial of the truth by the poor girl featured in Austen Ivereigh's article. In a recent programme of child survival in southern Malawi, HIV screening was offered to 700 pregnant village women. Almost all were happy for us to take their blood and do the test but no one came back to find out the answer. The social costs of knowing that you are HIV-positive are far too great.

None of these difficulties can be allowed to stand in the way of what is surely a world responsibility. But we owe it to the people of Africa to get it right. Small localised starts, however well-intentioned, can sometimes lead to disappointment and even disaster.

Tim Cullinan
Medical Emergency Relief Internatiuonal (Merlin)
London SE1

LETTERS
(from issue of 5 January 2002)

Sir, I was very impressed by Austen Ivereigh's article on Aids in Africa (The Tablet, 15 December), but it ignores some important issues which need to be opened up. I have become aware, as a teacher in the faculty of health sciences of Swaziland University, that the problem is much more complex than he suggested.

The Aids epidemic is even worse here than in Mozambique, which Austen Ivereigh visited: a recent estimate was that 35 per cent of the entire population of Swaziland are HIV positive, with some local variation.

If this disaster is going to be tackled, some of the complexities must be understood by anti-Aids workers.

Why does Thabo Mbeki, President of South Africa, oppose treatment of people with Aids? Why should he react in such a way? It would seem incomprehensible in the West, but I offer an interpretation.

In traditional African belief, disease is not caused by micro-organisms, but by witchcraft. On the whole, and I speak with confidence as the teacher of future medical personnel, the notion that abstention from sex or the use of condoms will abate the problem is simply not believed. Those suffering from Aids-related disease know that Western medicine has no answer.

If this is so, then the prolonging of the lives of Aids sufferers will only compound the problem: many at least will not take protective measures or abstain from sex: "I am a man!" - and the supply of cheapish drugs will not help in the long run. As a matter of fact, even at 10 per cent of world prices, these drugs are prohibitively expensive here. I know of doctors who have left this country in despair.

More than half their patients are HIV-positive; but they reject both the basis of the diagnosis and the recommended change of behaviour. The usual reaction is to seek another doctor who has more power to effect a cure.

My conclusion is, I am afraid, that anti-Aids agencies are at best wasting their time, unless the local cultural situation is taken into account.

Paul Potts
University of Swaziland
Mbabane - Swaziland

LETTERS
(from issue of 19 January 2002)

How to combat Aids

Sir, Both Tim Cullinan and Paul Potts (Letters, 22/29 December 2001, and 5 January 2002) have first-hand knowledge of Aids in Africa and of the complex issues which surround it, and are therefore well qualified to respond to the Sant�Egidio Community�s Aids project in Mozambique, described recently by Austen Ivereigh (The Tablet, 15 December 2001). But their arguments reflect a view of the epidemic which has hardened over time and which underpins the thinking of the United Nation�s Aids agency UNAIDS and other international bodies. The shared assumption is that the economic, social and logistical obstacles to treating Aids in Africa are so great that it is impossible effectively to cure the millions of HIV infected sub-Saharan Africans.

Of course, they are right. But what sounds strange to me is the assumption that all the infected should be treated. Millions die every year of malnutrition; but that does not stop programmes giving an effective but necessarily partial response to the problem of malnutrition. Tuberculosis still rages in Africa, yet TB initiatives have all but eradicated the disease in a part of the population. Should such programmes also be suspended, because not all the malnourished or those al risk from TB can be dealt with? Even in mass vaccination programmes, there are sharply varying policies and initiatives; if it were not for such inconsistencies, we would have eliminated many infectious diseases long ago. Why, then, when people speak of Aids in Africa, do they speak only of prevention and never of a therapeutic response, how-ever partial? Aids cannot be controlled by prevention alone. Some 25 million infected Abi1. are there to tell us that this policy has failed.

Some of the obstacles are highlighted by your correspondents. Cullinan notes that 700 pregnant village women in Malawi accepted HIV screening but failed to come back for the results. But why should they, when the results mean the knowledge of an assured early death and social stigma? Our experience shows that when a pregnant woman is offered a test and assured of treatment that will cure both her and her baby, the test becomes a much more reasonable and acceptable option.

Anti-retroviral drugs are already used in Africa, mainly by the rich, who have access to facilities where the therapy can be administered and monitored in controlled conditions. Our project is making these facilities available to a larger number of people, beginning this year with 1,500 pregnant mothers in Mozambique.

It is true that anti-retroviral drugs cost too much. But not everyone is medically eligible. Only that part of the population which meets the therapeutic criteria established in international guidelines can receive antiretroviral therapy. There has been much research and reflection in the West on whether the benefits of a prolonged treatment outweigh the costs in terms of side effects. We are currently awaiting the conclusive results of studies into intermittent treatment, which have the benefit of limiting those side effects.

As for the rest, your two correspondents are quite correct. It is extremely hard to communicate the idea of a sexually-transmitted virus to a population largely ignorant of micro-organisms; which is why Sant�Egidio has organised long and intensive courses of health education for our patients undergoing the treatment (who we hope will in turn educate others). It is also true as Cullinan points out - that there are very few health systems in sub-Saharan Africa with the resources to administer anti-Aids therapy. For this reason the Sant�Egidio programme bypasses hospitals. Our purpose-built laboratories monitor drug-resistant strains, sexually transmitted diseases and TB. The therapy is administered directly to the women in their houses by trained health workers who also ensure proper levels of nutrition and hygiene. Our partner in this �home help� part of the programme is Sue Ryder Care, one of the most experienced agencies in this field.

Aids threatens the development of all of Africa. Today the problem is immense; tomorrow it will be uncontrollable. In facing Aids in Africa, we should not be afraid to attempt a response based on treatment. What we should really be afraid of is what will happen if we continue to do nothing.

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(ITALIANO)
Rispondo con piacere alle due lettere pervenute in relazione all�articolo ��..AIDS in Mozambico��. Per un doppio motivo: il primo � che a scriverle sono due lettori con una ottima conoscenza del problema, consapevoli dei complessi fenomeni che si intrecciano attorno all�epidemia. Il secondo � che le loro tesi riecheggiano argomentazioni pi� volte sostenute anche in autorevoli sedi, presso agenzie internazionali come l�UNAIDS o altre, tesi che tuttavia costituiscono nel loro insieme un curioso paradigma che negli anni si � formato in relazione all�epidemia da HIV. Mi spiego meglio: entrambi i lettori sostengono ad esempio che enormi difficolt� di ordine economico, sociale e organizzativo impediscono una efficace cura dei milioni di persone HIV �infected. Questo � innegabile, ma quello che �suona� strano nel ragionamento � l�idea sottintesa che tutti dovrebbero essere curati. Milioni di persone muoiono ogni anno per denutrizione, ma questo non impedisce che programmi e iniziative diano una efficace ma del tutto parziale risposta al problema della malnutrizione. Dovremmo allo stesso modo sospendere questi programmi?La tubercolosi dilaga in Africa eppure questo non impedisce che si attuino interventi che raggiungono solo una parte della popolazione. Persino in campo vaccinale, che rappresenterebbe di per s� un elettivo tipo di intervento di massa, assistiamo ad azioni e politiche del tutto disomogenee, in cui spesso l�autentico criterio ispiratore � rappresentato dalla disponibilit� di fondi. Se non fosse cos� avremmo eradicato molte malattie infettive. Potrei continuare a lungo citando la malaria o altre condizioni morbose in cui peraltro il problema delle resistenze � presente e serio. Perch� quando si parla di AIDS si deve parlare solo di prevenzione e mai di una risposta, seppur parziale, al problema, in senso terapeutico?

D�altra parte siamo ben consapevoli che i problemi di ordine sociale siano immensi. Mi chiedo tuttavia se il rifiuto di ritirare una risposta ad un test che potrebbe suonare come una condanna senza appello sia poi cos� strana. Informare i cittadini testati della possibilit� di una cura per s� e per il proprio bambino, restituirebbe un senso di speranza e di ragionevolezza alla proposta. Chi vorrebbe effettuare un test il cui unico risultato sarebbe quello di sapere che si � condannati senza speranza? Per altro verso il CDC di Atlanta ha aiutato il governo mozambicano a mettere a punto un sistema sentinella basato su centri materni. Il sistema funziona egregiamente. Io credo che le difficolt� non siano da sottovalutare, ma anche che una eccessiva enfasi su di esse ci ha portato ad assumere come vero un paradigma senza fondamento e cio� che l�AIDS poteva essere controllato con la sola prevenzione. 25 milioni di infetti stanno a dirci che questa politica � fallita. In Africa la terapia antiretrovirale � praticata. Dai ricchi ad esempio, dai quadri dirigenti che tuttavia non hanno spesso a disposizione idonee strutture per il controllo ed il monitoraggio della terapia, o di clinici realmente preparati per somministrarla. Io credo che un risultato importante ed atteso del progetto in questione sia almeno quello di offrire le elementari facilities per una ragionevole somministrazione della terapia, in condizioni controllate.

Per il resto i due lettori hanno perfettamente ragione: � assai difficile far digerire l�idea di un contagio sessuale a popolazioni che non hanno idea dell�esistenza di microrganismi. Per questo il programma di Sant�Egidio contempla prolungati ed intensivi corsi di educazione sanitaria e di accompagnamento dei pazienti. E� anche vero che l�organizzazione sanitaria e gli interventi attorno all�AIDS rappresentano qualcosa di troppo sofisticato per i sistemi sanitari africani. Per questo Sant�Egidio propone un intervento di tipo orizzontale e complessivo che parte ad esempio dalla ristrutturazione di maternit� e di laboratori per giungere a programmi di bio-sicurezza, sostegno nutrizionale, diagnosi e controllo delle STD, della Tubercolosi e � ovviamente- di tipo preventivo. L�assistenza domiciliare, inoltre, � cogestita assieme ad una delle pi� note ed impegnate agenzie in questo campo- la Sue Ryder- che vanta un�esperienza invidiabile.

I farmaci antiretrovirali costano troppo, ma- ancora una volta- essi andrebbero somministrati solo ad una parte degli infetti, quella che incontra i criteri terapeutici stabiliti dalle linee guida internazionali.

Occorre inoltre far presente che si � avviata in Occidente una estesa riflessione sulla utilit� e sul dubbio profilo costi/benefici di una terapia continuata. Siamo in attesa di studi conclusivi sulla suggestiva ipotesi di schemi di terapia intermittente, i quali, tra l�altro avrebbero il pregio di limitare gli effetti avversi che si manifestano dopo lunghi e protratti periodi di somministrazione.

Si potrebbe continuare ma forse vale la pena soffermarsi un attimo sulle conseguenze della nostra scelta di affidarci al paradigma preventivo. La minaccia dell�AIDS coinvolge ormai lo sviluppo di un intero continente. Oggi il problema � immenso, domani sar� incontrollabile. Non varrebbe la pena di considerare l�AIDS anche come una storica chance per riformare i sistemi sanitari africani e per proteggere e dare impulso allo sviluppo in quel continente? Io credo che non si debba aver paura di toccare il problema e di tentare una risposta. Mi fa molto pi� paura l�idea di quel che accadr� se non faremo niente.

(Professor) Leonardo Palombi
Director, Community of Sant�Egidio�s Aids programme Rome