Simple Antibiotic Urged for Africans With H.I.V
New York Times (04/06/00) By DONALD G. McNEIL Jr.
PARIS, April 5 -- The 23 million Africans infected with the virus that causes AIDS should be given regular doses of a common and affordable antibiotic to ward off fatal secondary infections, the World Health Organization and the United Nations AIDS program said today.
The groups based their recommendation on encouraging preliminary studies, and added that if the results are borne out, the impact could be dramatic. Virtually all of those infected with the virus will still die prematurely of AIDS, but many could add years to their lives and have longer gaps between debilitating complications.
The drug, known as trimethoprim-sulfamethoxazole or as cotrimoxazole, is marketed as a generic medicine in the United States, treating a variety of ailments including urinary tract infections and bronchitis; it is best known as Bactrim, a trademark of Roche Pharmaceuticals. In Africa, continuing use of the drug can cost as little as $8 a year per patient. Its use to protect against disease in Africa was endorsed for the first time last week by AIDS experts who convened in Zimbabwe to assess the studies.
The Clinton administration is spending more than $100 million to fight AIDS abroad and wants to raise that to $325 million in next year's budget. It may spend millions to help distribute Bactrim, but has not yet calculated how much to commit.
"We did some of the original work on this, and we're extremely enthusiastic about it," said Dr. Helene Gayle, director of the AIDS division of the United States Centers for Disease Control and Prevention in Atlanta. "It's cost-effective, it's ready to roll, and it may become an important component of the program."
Endorsing the drug was "a difficult decision because the research is not definite yet," said Dr. Peter Piot, executive director of Unaids, a consortium of United Nations agencies. But he also said, "This drug, which is widely available and affordable, can prolong the life of H.I.V.-infected people and improve their quality of life."
For years Bactrim has been prescribed in wealthy countries to ward off pneumocystic carinii pneumonia, which was once a primary killer of Americans with AIDS. In Africa, its use seems to be appropriate in handling bacterial pneumonias, diarrheal diseases and some septicemias, and perhaps against parasitic infections of the brain and intestines.
Because the studies have been brief, it is impossible to say what the long-term effects will be, warned Dr. Badara Samb, an adviser at Unaids. But a one-year study in the Ivory Coast found that Bactrim cut death rates by 50 percent among the group that took it, he said, and a second study in the same country found that it cut the number of dangerous complications like diarrhea and pneumonia by 50 percent.
"We can't know what will happen in five years, but we can't wait for five years to find out," Dr. Samb said. "Gaining even six months of life is not negligible, and six months when people are not in bed, sick, all adds to the quality of their lives."
More recent studies in South Africa and Malawi were also optimistic that the drug was effective and could be safely given to H.I.V.-infected Africans, who normally have more meager diets than Americans, have less access to clean water, do more physical labor and are subject to more parasitic disease.
The rate of new H.I.V. infections in Africa is estimated to be 100 times that in the United States.
In some countries, as many as 25 percent of all adults are infected, and in Botswana, the country with the highest rate, AIDS has slashed life expectancy from nearly 70 years to 41, according to the United Nations.
Only a tiny number of Africans can afford the $15,000 annual cost of the "cocktails" of drugs that can prevent the infection from progressing to full AIDS. Many African countries have national annual medical budgets of as little as $6 per citizen. No public health system and almost no employers pay for protease inhibitors or other expensive drugs.
Many Africans who develop AIDS die rapidly of diseases like tuberculosis or malaria, which are common in the region. Both are usually treatable with relatively inexpensive drugs, though many Africans may be unable to reach urban hospitals that could provide these medicines, and in very poor countries, even urban hospitals may lack them.
Others fall prey to parasitic diseases that are common in parts of the continent.
Unaids and the World Health Organization acknowledged that the more the drug is used, the more danger there is of creating germs resistant to it. But the benefits were judged to outweigh that risk.
In wealthy countries, the use of Bactrim to prevent pneumocystis carinii pneumonia may start to decline. A Swiss study cited in the New England Journal of Medicine a year ago found that the so-called drug cocktail was so effective that Bactrim was unnecessary.
Although India, Bangladesh, Thailand and other Asian countries have an AIDS epidemic rivaling Africa's, the World Health Organization and Unaids did not yet recommend the preventive use of Bactrim there, awaiting more studies.
Bactrim costs as little as 21 cents per pill in the United States, and with bulk buying by health agencies for Africa, preventive use can cost $8 to $17 a year per patient. It is already widely available in Africa as a treatment for childhood pneumonia and bacterial diarrhea.
"If you asked caregivers there about it, more than 99 percent of them would know the drug," said Dr. Samb, who is from Senegal. "I'd say you'd have an 80 percent chance of finding it in a village pharmacy."
Doctors Without Borders, the Nobel Prize-winning group of doctors working in poor countries and pressing for global access to inexpensive drugs, backed the decision.
"Bactrim is very cheap, and it's not too complicated to implement, so if they have good data on mortality, I'm sure it's a good decision," said Bernard Pécoul, director of the group's Access to Essential Medicines campaign.