An Aids patient in Zambia: Drugs are beyond the
reach of most African sufferers

Charles Nelson is nervous. Every three months he comes to a clinic in Washington DC for a health check, and blood tests. It's the blood tests he can't stand - after 14 years of life with HIV and countless visits to the lab for analysis of his blood - the sight of a needle piercing his skin still makes him wince.

In a couple of minutes five small glass vials are filled with his blood. Within days he'll have new information about the state of his body's immune system, and the effectiveness of the anti-viral drug therapy upon which his life now depends.

Charles Nelson learned he had HIV in 1986. He was a 25-year-old student. In the midst of America's Aids panic of the late 1980s he assumed he would develop full-blown Aids and die.

But he was an early recipient of the first important HIV inhibiting drug to be produced in America, AZT, and by the mid-1990s he was taking a complex anti-retroviral cocktail which was, and still is, keeping his HIV in check.

So Charles Nelson can work full-time, he can travel and enjoy life. But he cannot relax. His health depends on vigilance and discipline.

In America there are now close to a million people living with HIV. Last year only 20,000 died of Aids, which means the US is spending billions of dollars on drugs, healthcare and other support services to combat the virus.

People with HIV and Aids need effective, long-term support. In downtown Washington DC they get it from the Walker-Whitman clinic. This unremarkable building on a shabby street houses a dynamic institution generating energy and enthusiasm for the fight against Aids. Here, clients - they're never called victims - come in for counselling, for food packages, for prescription drugs.

In a city where many people with HIV are poor, black and addicted to hard drugs the clinic is a lifeline. Its budget is a mix of federal grants and private sector donations - its very presence is a sign of the success Aids activists have had in forcing America to face up to the epidemic.

Why are the drugs capable of inhibiting HIV having no impact in the countries where the virus is now rampant?

The multi-billion-dollar pharmaceutical corporations of America have spent millions of dollars testing and manufacturing HIV-inhibiting drugs. They are bitter rivals in the market place, but on one key issue they've long had a common interest - using international copyright law to maintain their grip on the manufacture, distribution and pricing of Aids drugs, such as AZT, worldwide.

Throughout the 1990s the drug companies fought vigorously to protect their privileges. Their argument was simple: infringement of intellectual copyright law to allow poor countries cheap access to Aids drugs would be the thin end of a dangerous wedge.

Pirating would run riot across the world - and American business would suffer. If copyright is not protected, said representatives of the pharmaceutical giants, who will bother investing in the research and development necessary to continue the fight against Aids?

The battle over patents and pricing came to a head in South Africa. The South Africans passed a law enabling local production, or importation of cheap HIV drugs.

The American pharmacetical companies were furious, and their friends in Congress demanded tough sanctions. Vice President Al Gore, about to launch his presidential bid, warned the South Africans in early 1999 that relations between Pretoria and Washington could be damaged.

In fact it was Al Gore who was damaged. As he tried to launch his presidential campaign with rousing events in the summer of last year Aids activists hounded him - disrupting rallies and embarrassing the candidate.

In the words of Wayne Turner of ACTUP - the Aids Coalition to Unleash Power - "We used the politics of shame. We can't afford to buy politicians with huge donations, but we can show up at political events and shame politicians into implementing policies that will save peoples' lives".

Last summer Al Gore announced a change of heart - the US administration dropped its opposition to the South African initiative on cheap AIDS drugs. Indeed concessions on home-grown drugs manufacturing and pharmaceutical imports have now been applied across sub-Saharan Africa.

There is growing evidence that the US Government does, at last, regard the global Aids epidemic as a policy priority - officials even describe it as a "national security threat".

But even if cheaper anti-retroviral drugs can be channeled into the areas where they are most needed, that will do little to alleviate the crisis. Because pills alone are of little use in countries without the most basic healthcare - in cultures untouched by Aids education, and in economies collapsing under the weight of mass poverty.

America's challenge now is to move on from the argument over drug availability and forge a new, far-reaching partnership with the countries at the centre of the Aids epidemic.

Cornelius Baker of the Walker Whitman clinic has spent the last decade fighting to improve the lot of people with Aids in the United States. Now he wants to use that experience to launch a global crusade.

"We know that in the absence of greater assistance being provided 23 million people stand on the verge of death", he says. "To sit by and do nothing is to participate in genocide."