From the Washington Post: Dead Wrong on AIDS
Please send your thanks to Amir, Ken and Marty!
Dead Wrong on AIDS
By Amir Attaran, Kenneth A. Freedberg And Martin Hirsch
Friday, June 15, 2001; Page A33
Andrew Natsios, the Bush administration's new chief of the U.S.
Agency for International Development (USAID), has made a very bad
start with regard to one of his agency's primary missions: dealing
with the scourge of AIDS in Africa. Natsios has made comments re-
cently on the prevention and treatment of the disease in Africa that
are, to say the least, disturbing, if not alarming. His comments ap-
peared last week in the Boston Globe and in testimony before the
House International Relations Committee.
On both occasions he argued strenuously against giving antiretroviral
drug treatment (the AIDS treatment used in the United States today)
to the 25 million Africans infected with HIV. Although Natsios agrees
that AIDS is "decimating entire societies," when it comes to treating
Africans, he says that USAID just "cannot get it done." As Natsios
sees it, the problem lies not with his agency but with African AIDS
patients themselves, who "don't know what Western time is" and thus
cannot take antiretroviral drugs on the proper schedule. Ask Africans
to take their drugs at a certain time of day, said Natsios, and they
"do not know what you are talking about." In short, he argues that
there is not a great deal the agency he leads can do to help HIV-
Under his guidance, USAID will not offer antiretroviral treatment but
will emphasize "abstinence, faithfulness and the use of condoms" as
the essence of HIV prevention. (He also supports distribution of a
drug that blocks transmission of the disease from mother to child,
and drugs to fight secondary infections.) While this might save some
of those not yet infected with the virus, it in effect would condemn
25 million people to death, and their children to orphanhood. As the
administration's man in charge of international assistance, including
helping Africans with AIDS, Natsios should know better. His views on
AIDS are incorrect and fly in the face of years of detailed clinical
Take the issue of whether AIDS should be dealt with by prevention or
treatment. In backing prevention to the total exclusion of treatment,
Natsios favors only modest changes in the strategies that USAID has
relied on for the past 15 years, which by themselves have clearly
failed to stem the pandemic. This is why expert consensus now agrees
that prevention and treatment are inseparable -- or, in the authori-
tative words of the UNAIDS expert committee, "their effectiveness is
immeasurably increased when they are used together." The same conclu-
sion has been reached by countless other experts, including 140 Har-
vard faculty members who recently published a blueprint of how anti-
retroviral treatment could be accomplished. Harvard physicians are
now treating patients in Haiti, and others are achieving similar
treatment successes in Cote d'Ivoire, Senegal and Uganda.
It is also disturbing that Natsios chooses to exaggerate the diffi-
culties of AIDS treatment, as if to single-handedly prove it would be
impossible throughout Africa. Whether Africans can tell "Western
time" or not is irrelevant; nearly all antiretroviral drugs are taken
only twice a day -- morning and evening. Sunrise and sunset are just
as good as a watch in these circumstances. Nor is Natsios correct
when he says the drugs have to be "kept frozen and all that." Not a
single antiretroviral drug on the market today needs freezing. In
fact, some bear warnings not to freeze them. Natsios also said that
"the problem with [delivering] antiretrovirals . . . is that there
are no roads, or the roads are so poor." In fact, millions of AIDS
patients live in cities such as Cape Town, Dakar or Lagos, where the
streets are teeming with cars. Natsios says that antiretroviral drugs
are "extremely toxic," so that as many as "forty percent of people .
. . who are HIV positive do not take the drugs . . . because they get
so sick from the drugs that they cannot survive." This is a view
shared by no one in the medical establishment today. Clinical and
epidemiological studies by the Centers for Disease Control and the
National Institutes of Health have shown that these drugs are safe
for most people and prolong life by many years.
Two facts are clear. The first is that, in Abidjan and Johannesburg,
as in Manhattan, AIDS prevention and treatment must go hand in hand.
And we can accomplish this if the Bush administration contributes
adequately to an international trust fund for that purpose (it has so
far promised only $200 million, or just 72 cents per American). The
second fact is that Andrew Natsios, by virtue of his unwillingness to
acknowledge the first fact and his willingness to distort the true
situation in Africa before Congress, is unfit to lead USAID and
Amir Attaran is director for international health research at Harvard
University's Center for International Development.
Kenneth A. Freedberg is a physician at Massachusetts General Hospital
and an associate professor at Harvard Medical School.
Martin Hirsch is director of clinical AIDS research at Massachusetts
General Hospital and a professor at Harvard Medical School.
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