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WASHINGTON — If you're an American female between the ages of 15 and 24, the probability that you're living with AIDS is less than one half of one percent. Consider yourself fortunate.

But if you're a young woman in Botswana, your chances are somewhere around one in three — and the likelihood that you're being treated with the newest, most effective drugs is almost nonexistent.

When antiretroviral drugs were introduced several years ago, world leaders pledged that by the end of 2005, they would treat half the 7 million global AIDS sufferers who needed the innovative medication to survive. But David Bryden of the Global AIDS Alliance said they are likely to fall far short of that goal, providing those treatments to only seven percent of the people who need them.

Despite the failure to reach their previous goals, leaders at the G8 summit in July again pledged universal antiretroviral treatment, this time by 2010. But the best intentions of global leaders will take a lot more work than just shaking hands. Even when everyone agrees on the solution, drug dissemination programs face a host of problems, both economic and sociological, as they tackle the AIDS crisis in Africa.

One of the greatest challenges in distributing antiretrovirals in Africa is, quite simply, the cost of these medications, which are often needed for the entire lifespan of the patients.

"Although prices have come down dramatically, because large quantities are needed for 'life-long' treatment, these medicines still need to be paid for by the donor community," said David Lee of Management Sciences for Health (MSH), a private organization that works worldwide to improve access to primary health services.

While some countries have found ways to produce antiretrovirals for less money — Thailand, India and Brazil all produce generic antiretrovirals — global discount drugs are perceived as a threat to the U.S.-based pharmaceutical companies who invented the drugs and hold the patents.

Through the Central American Free Trade Agreement, Bryden said, some U.S. companies agreed to slash prices on AIDS drugs in exchange for patent protection. On one hand, the price cuts will allow Latin American countries like Argentina to treat 100 percent of its AIDS patients needing antiretrovirals. On the other hand, they bar the development of even cheaper discount drugs.

Bryden also fears a trade agreement currently in the works between the U.S. and Southern Africa will have a similar effect - making the drugs more affordable, but potentially thwarting even cheaper generics production in Kenya and South Africa.

Though cost may be the largest obstacle to treating the world's AIDS sufferers, it is by no means the only one.

"African governments have [also] been struggling for years with poor [distribution] systems, not enough staff, etc.," said Amy-Simone Erand of MSH. "AIDS only makes things much, much worse."

Access to antiretrovirals is difficult to guarantee because even if the medicines were universally available, there are very few stable health care distribution networks established in developing countries. And while it is difficult to pinpoint any one nation that is the worst off, Erand points to South Africa as a prime example of this difficulty.

"South Africa poses significant challenges because of sheer numbers, weak health systems and leadership," Erand said. "The HIV/AIDS pandemic has severely diminished the capacity of the health workforce in developing nations. The lack of human resources and strong management systems is not new, but the situation has reached crisis proportions in many countries. Staffing shortages and imbalances, work overload, declining morale and weak management systems all add to the crisis."

Another difficulty is the mindset that is prevalent amongst more pragmatic AIDS treatment policies. Traditionally, the fight against AIDS — and its funding — has been focused on prevention, Bryden said. That fight operates under the morbid but practical assumption that while current AIDS patients are difficult to save, new cases can be stopped through education, condom use and other preemptive measures.

South African President Thabo Mbeki has been one of the biggest proponents of this view, arguing that poverty and lack of education are the real causes of AIDS. Based on this philosophy, the largest anti-AIDS campaign in South Africa is LoveLife, which relies on youth activities like sports teams and group trips to combat the spread of HIV. The infection rate remains staggeringly high in South Africa, at 28 percent of the total population.

Bryden and his colleagues don't dispute the LoveLife methodology, but they also argue that treatment plays a critical role in prevention.

"The two really do go together," Bryden said. "As you are treated, the amount of virus in your blood goes down, so it actually becomes harder for you to transmit it to others."

In most countries, including the U.S., there is still a painful and social stigma attached to HIV and AIDS. In India, sub-Saharan Africa and other parts of the world, this stigma is even greater for women.

According to UN AIDS reports on Botswana, the nation with the highest prevalence of AIDS in the world, the disease is far more common among young women than among young men (32 to 36 percent versus 13 to 18 percent). Most of these women contract the disease from unfaithful husbands or boyfriends. Even though they are not to blame, these women are still afraid to admit their condition to their families or even themselves. That fear can prevent these women seeking testing and treatment altogether.

"When you go to get yourself tested anywhere, really, there's a certain amount of stigma and discrimination and shame," Bryden said. "That's one of the reasons why many people are advocating AIDS testing as part of more general medical treatment so it's not as if you're walking under a door marked 'Get Your AIDS Test Here!'"

— By Megan Doughty (Medill News Service)

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