BY GEOFFREY COWLEY YTHEGRIM standards of subSaharan Africa, 18-year-old Henry Kiiaka is not doing too badly. He attended high school near Kampala, Uganda, and he now earns $30 a month helping a farmer keep his books. Sporting a wide smile and a . bright yellow button-down shirt, the former class president marvels at some of his schoolmates' low spirits. "Sometimes you will find a student just hiding and crying in a room;' he says. "Sometimes they commit suicide!" Despite his cheerful manner, Henry is TAKING no stranger to CARE: pain. He lost his Josephine Nakfather as a child, and his mother agwa, 6• is one died ofAIDS of the 110,000 Ugandan kids three years ago, with HIV. Here, leaving him to care for his four her grandmother younger siblings. comforts her. Two of his three teenage sisters still refuse to admit that the disease has touched their family, but Henry doesn't have the luxury of denial. His half brother, IO-year-old Ronnie, is living with HIV-and as head of the household, he is the boy's only lifeline. "Sometimes I have times alone;' Henry confides while sitting with the downcast child at the pediatric clinic at Mulago Hospital. "One or two or three drops of tears:' As President George W. Bush travels through Africa this week, he will hear worse. Civil wars VANESSA VICK fester in five countries. Poverty and food shortages are rampant. And AIDS is stripping whole societies of the parents, farmers and teachers who could tum things around. As Secretary of State Colin Powell declared recently, "HIV is now more destructive than any army, any conflict, any weapon of mass destruction." Yet as Bush himself seems to recognize, the prospects for stopping this scourge have never been brighter. Though he'll stump for trade and economic development during his fivecountry trip, the centerpiece of his Africa policy is a $15 billion AIDS effort. The president is not known for his interest in global health or poverty, but he has recently touted the five-year initiative with the zeal of a convert. Signed into law this spring, the measure authmizes up to $3 billion a year for AIDS programs in 14 countries including 12 in Africa. And unlike earlier U.S. efforts, this one doesn't bypass people already infected with the virus. The plan's goals include lifesaving treatment for 2 million patients. It's not as simple as putting pills in the mail. Right now, more than 4 million Africans are sick enough to require AIDS treatment, but only 50,000 have access to it. Even if the drugs themselves were free, experts doubt that more than a fourth of those needing treatment could have access to clinics capable of delivering it. With 8,500 people dying every day, the first job is simply to get drugs into existing clinics and ration them to the sickest patients. It may sound straightforward, but as health workers are now discovering, the task is as complex as it is urgent. When resources are scarce, saying yes to one patient can mean saying no to another. Any waste of resources-buying drugs from the wrong distributor, shipping them inefficiently- can translate into fewer treatment slots and more lost lives. And haphazard treatment can harm communities as well as patients by speeding the emergence of drug-resistant virus. "The pressure is on us to show that treatment can HE BUSH PROGRAM MAY not reach that benchmarkthe actual funding levels are subject to congressional whim-but the measure itself heralds a new era in AIDS control. Until recently, few experts considered treatment a viable strategy for a continent where 30 million people are infected with HIV and many lack even the most basic health services. Triple-drug cocktails may have made HIV survivable in the United States and Europe, the reasoning went, but hungry peasants were in no position to tackle such costly, complicated treatment regimens. For them, prevention was the only cure. The argument made sense in the late 1990s, when a year's worth of triple-drug therapy cost $10,000 or more. But prices have plummeted in the past few years. Dying people can now be rescued with generic regimens that cost just a dollar a day-and that shift has created tremendous momentum for change. Governments, foundations, drug companies and international agencies are now racing to fund treatment initiatives in poor countries-and the public-health community is scrambling to translate good intentions into programs that actually work. "Large-scale treatment is no longer a fantasy," says Dr. Peter Piot, the director ofUNAIDS. "The challenge is to do it rationally." For daily reports, including audio and video, from Bush's Afri ca trip, go to Newsweek MSNBC com 26 NE WSWEEK JUL Y 1 4 , 2 003 TOP PHOTOGRAPH BY GARY KNIGHT FOR NEWSWEEK LAND OF work in impoverished settings," says Dr. Allan Rosenfield, dean of Columbia UniverORPHANS: sity's Mailman School of Public Health. "Resources are opening up, but everyone's Dr. Philippa under a microscope." Musoke of Rosenfield, an obstetrician by training, Uganda's Mulago is spearheading an effort aimed specifically at keeping HIV-positive mothers alive. Hospital examines Launched last year with $50 million in foundation grants, the initiative is still too a young girl who young to count as a success, but it marks lost her parents one of the boldest attacks yet on Africa's burgeoning orphan crisis. In the late 1990s, to AIDS. The before drug prices fell, researchers discovered that as little as one dose of anti-HIV disease has medication could sharply reduce a woman's orphaned risk of infecting her baby during delivery. Health groups mobilized to test and treat llmillion pregnant women during that brief window children in subof opportunity. The resulting "MTCT" (mother-to-child-transmission) initiatives Saharan Africa. have since prevented thousands of pediatric infections. The catch is that many of the spared kids have grown up (or perished) as AIDS orphans. Rosenfield's "MTCT-Plus" initiative addresses that problem by helping existing clinics provide lifelong treatment for parents. "Our aim," he says, "is to develop a family-centered care model that can be replicated by others around the world." So far, the program has reached roughly 500 families in seven African countries. When a woman tests positive at one of 10 participating clinics, she gets extensive counseling on everything from nutrition to discussing HIV with her partner and kids. Few enrollees require treatment right away, but when they or their immediate family members reach that point, community health workers monitor their adherence to the prescribed regimen. Organizers had worried that women might shun the program as long as they were healthy, preferring to hide their HIV status from their partners and families. But the prospect of care is a powerful antidote to stigma. "Now the woman can actually feel like she makes a difference," says Dr. Philippa Mosoke, the director of an MTCT-Plus program at Kampala's Mulago Hospital. The MTCT-Plus model has obvious virtues. It recognizes women as the anchors of families and communities. And because it builds on existing programs, it can deliver treatment quickly and efficiently. But family-centered care is not the only kind required to fight AIDS in Africa, for women with families are not the only ones dying. Thirty-seven-year-old Margaret Lubega has lost six of her seven siblings to AIDS in recent years. She herself was near death when she started treatment at the Mulago clinic's MTCT-Plus program in May. She's now SOURCES: UN AlOS, 81LL ANO MELJ NOA GATES FOUNDATION. PHOTOS BY PABLO MARTINEZ MONSIVAIS AND DENIS FARRELL- AP: GRAPHIC BY KEVIN HAND. TEXT ANORESEARCH BY KAREN YOURISH- NEWSWEEIC JULY 14 , 2003 NEWSWEEK 27 healthy-and secure in the knowledge that her partner and two infected children will get treatment when they need it. Lubega's last surviving sister may not be so lucky. She, too, is HIV-positive, but because she hasn't given birth recently, she has no way into the program. "She tells me, 'Please don't miss a day when taking those drugs';' Lubega says. Other doors could open as foundations, corporations and relief groups race to start new treatment programs. But experts now agree that stopping AIDS will require more than a patchwork of small initiatives. Former president Bill Clinton recently formed an HIV/AIDS 'Treatment Consortium to help developing countries create comprehensive national progran1s; his foundation is now working with the governments of Rwanda, Mozambique and Tanzania to develop treatment and prevention plans. And though Bush's $15 billion initiative is still more an idea than a policy blueprint, it signals a commitment to large-scale intervention. Since unveiling the initiative last winter, Bush has spoken often of the "moral imperative" to fight AIDS and the ''hopeless poverty" it engenders. The issue has obvious political value-the Congressional Black Caucus has lobbied for more attention to AIDS, and so has the evangelical right-but aides say the measure is an expression of core principles. "Anlerica makes this commitment for a clear reason, directly rooted at our founding," the president himself said last week. "We believe in the value and dignity of every human life." The challenge, of course, is to translate good intentions into good works. Critics fault Bush for funding the new initiative through U.S. government agencies instead of working through the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has lower overhead and is set up to deliver services immediately. But whatever its shortcomings, the Bush plan should serve as a catalyst for action-and it's not the only cause for encouragement. Several hard-hit countries have already succeeded at setting up comprehensive AIDS initiatives. Brazil has achieved a 70 percent reduction in AIDS deaths over the past decade by integrating prevention efforts with an aggressive, low-cost treatment program. In Botswana, where adult HIV rates approach 40 percent, partnerships involving the government, the Gates Foundation, drug companies and the Harvard AIDS Institute have gotten 8,000 people onto treatment in the past 18 months alone. These are small victories-one or two or three drops, as Henry Kiiaka might say-but they prove that more is possible. With JOHN NESS IN KAMPALA and TAMARA LIP PER in Washington 28 NE WSWEEK JULY 14, 2 00 3 BY TOM MASLAND OSEPH, A 28-YEAR-OLD communications student in Denmark, hadn't heard from his father in eight years. Then came a letter, smuggled out of the forests of eastern Congo in April. "We recently learned that you are still alive," wrote Joseph's father in a handwritten message that had been carried by a traveling merchant over hundreds of miles. "Praise the Lord. But as for me, your mother and two small brothers, we are the living dead. Your big brother and sister, with her daughter, were killed five years ago. We move according to the security conditions- the war hasn't stopped since 1996 .. . We're without food, clothes, medicine, with only the hope that God will come to our aid." No son could resist such a plea. Joseph begged family friends in Rwanda to try to smuggle a message back to his father, and to formulate a plan to help him escape the area where he is trapped-living "in slav-