In the country with the world's highest HIV rate, clinics have been running out of medicine. They break open the bottles of pills, divide them in half, and dole them out in small plastic bags to patients who worry that their lifeline is eroding.
"They say they don't know how they'll survive," says a young woman named Goodness, an advocate for HIV-positive people, who won't give her full name for fear of punishment by Swaziland's authoritarian government.
Dependent on AIDS medicine herself, she surveyed clinics and found patients quitting their treatment because of the shrinking supply of drugs. "Their hope is lost, and that's why they decide to default," she says. "It hurts. We don't know what to do."
On the ground in Swaziland, where today, on World Aids Day, 26 per cent of adults have the AIDS virus, the fight for antiretroviral medicine is a battle for survival. A financial crisis here has disrupted the supply of medicine, forcing a U.S. agency to step in with emergency stocks. Globally, the situation is slipping into the same crisis, with looming cuts to the biggest global AIDS fund.
The irony is that Swaziland could also be a symbol of how to end the pandemic. In this small African country, researchers are planning a landmark test: the first full-scale national trial of a Canadian-led treatment strategy that could reverse the spread of the virus.
The strategy, known as "treatment as prevention" and based on the concept of giving antiretroviral drugs to virtually everyone with the virus, has already proven to be 96 per cent effective in halting transmission of HIV in clinical trials. Now the scientists hope to expand it into a countrywide experiment in Swaziland, and then roll it out across Africa. But to do that, they will need money – and cash-strapped governments from Africa to Europe have been sending the opposite message this year.
Despite the financial uncertainties, a coalition of donors has begun laying the groundwork for a national trial in Swaziland, based largely on the ideas of Vancouver physician and AIDS researcher Julio Montaner, who has been promoting the treatment-as-prevention concept for the past five years.
So far $12-million has been allocated for the early stages of the project, which aims to cover 90 per cent of those eligible for treatment by 2014. Within the next decade, it aims to cut Swaziland's new infections by 50 per cent. The ultimate goal is to provide treatment to everyone with the virus, which would drastically reduce its transmission and virtually eliminate new infections in this country – and then worldwide.
For the AIDS community, 2011 has been a roller-coaster year: a year of excitement over new solutions and pride in recent achievements, mixed with deep frustration and anger that the world is unwilling to spend the money that could halt the pandemic.
U.S. Secretary of State Hillary Clinton predicted last month that the world could soon see "an AIDS-free generation." She said the disease could be halted by using treatment as prevention in combination with other strategies to inexorably reduce the new infections. In a world where 33 million people have the virus, and an estimated 10 million who need treatment are getting none, it seemed extraordinarily optimistic.
A few days later, new statistics from the United Nations showed that Ms. Clinton could be right. A massive multibillion-dollar increase in HIV treatment over the past five years has led to a 22-per-cent decline in AIDS-related deaths, averting the death of 700,000 people.
Yet just as this news was being celebrated, the world's biggest AIDS fund announced it was cancelling its next round of grants because of a shortfall in donations. The $22-billion Global Fund to Fight AIDS, Tuberculosis and Malaria, which has saved millions of lives by providing 70 per cent of antiretrovirals in the developing world, shocked the AIDS community by disclosing that it could do nothing more than try to keep alive its existing programs.
"I'm not allowed to characterize the desolate sabotage of the Global Fund as murder, but in the private depths of my soul, I really believe it is murder," said Stephen Lewis, the long-time Canadian activist and former UN ambassador on AIDS in Africa, in a fierce speech at Yale University this week.
"It's not just the fact that people will die, it's the fact that those who have made the decision know that people will die," he said. "What possesses the donor community to intensify the emotional and physical havoc? Do they regard Africans as casually expendable?"
What disturbs him most is that the cuts come at a time when AIDS could be rolled back with the new treatment strategies. "The carnage can cease," he said.
This is where Swaziland could become crucial. This year, new studies showed that Dr. Montaner's strategy could reduce the transmission of HIV to almost zero, but now the goal is to expand it to an entire country, and Swaziland has been chosen as the first.
"The Swaziland project is extremely important and needs to be supported," said Dr. Montaner, director of the B.C. Centre for Excellence in HIV/AIDS.
Until now, he said, the research on treatment as prevention has been based on highly controlled tests, mostly in wealthy countries such as Canada. "Will it work in a poor developing nation like Swaziland?" he asked. "It might lose some of its efficacy, but we're confident it will retain most of its efficacy. The sooner we do it, the sooner the policy makers will become confident in it."
Mr. Lewis, who helped obtain European funds to launch the Swaziland project, said there are always skeptics about new strategies. "To test the theory across an entire country is a dramatic way to put the doubts to rest," he said.
"Swaziland will become the model for accelerated treatment right across Southern Africa. It will be the kind of breakthrough that people will talk about for years to come."