Cheaper AIDS Drugs Pose More Dangers in Africa
New York Times- April 1, 2001
By BARBARA CROSSETTE
UNITED NATIONS, March 30 American foundations and African experts say that unless public health systems are strengthened in poor countries, the benefits of more AIDS drugs at lower prices could be undone by ineffective distribution or misuse, leading to the development of new strains of drug-resistant viruses.
Experts also say that while they welcome the promise of cheaper drugs, strict international quality controls must be maintained as more countries make and sell drugs to treat AIDS.
Two major meetings will be held in Africa in April to consider this and other issues surrounding the AIDS epidemic, in advance of a special high-level General Assembly session here in June on this global health crisis.
Peter Mugyenyi, director of the Joint Clinical Research Center in Kampala, Uganda where a meeting of African experts and American donors sponsored by the Rockefeller Foundation will take place from April 18 to 20 said in an interview that the sudden promise of more readily available drugs added urgency to the problem of poor health care systems.
"The fact that costs are being reduced means that the drugs are going to be more and more easily used," Dr. Mugyenyi said. "Now this has implications. One implication is that we need to prepare in advance for very wide use, so that we have in place facilities for monitoring the patients and the outlets for the drugs in a professional manner."
While Uganda has been a leader in Africa, along with Senegal, in building up public health and information systems to deal with AIDS, many countries in Africa and Asia do not have similar services. Prevention campaigns continue to lag, often because of the stigma attached to the disease or officials' squeamishness about talking openly about sexually transmitted illness.
The lessons learned in Africa may be applied in other regions, including South Asia, where India is expected to be the next epicenter of the AIDS epidemic. Gordon W. Perkin, director of the global health program of the Bill & Melinda Gates Foundation in Seattle, said in an interview that experts were focusing on southern and western India, particularly the Bombay area, where the sex trade was extensive. "Intervention now with a very strong, active prevention program, could make all the difference as to whether 10 million die or 100 million," he said.
Dr. Perkin is among those concerned about the critical need to administer new AIDS drugs correctly, which will be a big burden to many governments and local health authorities. "You're taking at least three separate drugs on different schedules, and some of them several times a day," he said. "It's a very difficult schedule to administer. There's a lot of concern about compliance that if you don't get large numbers of people taking them consistently and correctly, you risk the probability of getting a resistant strain of H.I.V. emerging. Just like antibiotics."
Arthur C. I. Mbanefo, Nigeria's ambassador to the United Nations, said in an interview that he hoped that topics like this would be raised at an African regional meeting on AIDS in the Nigerian capital, Abuja, from April 25 to 27. Heads of government have been invited to that meeting to prepare for the General Assembly session.
"People have to be properly educated," he said. "Since the drugs we are talking about are not curative drugs, it is most important the people continue to focus on preventing the infection.
"For those who are infected, who are going to live with this for the rest of their lives, there has to be the ability to set up special pharmacies or hospitals where they can get the drugs at a subsidized rate. You don't get this price concession then just fold your hands."
Mr. Mbanefo said there was great opportunity for corruption in making, selling or distributing AIDS drugs. Other Nigerian experts say that studies have found that over- the-counter sales of pills to the poor are often fraudulent or substandard.
The organizers of the General Assembly session in June Ambassador Penny A. Wensley of Australia and Ambassador Ibra Deguθne Ka of Senegal want to move the conference beyond the issues of drug prices and accessibility.
"There's no doubt that access to drugs is important for the huge numbers of people who are suffering from H.I.V.-AIDS and are currently unable to afford them," Ms. Wensley said in an interview. "But we have to deal with this in a comprehensive and sustainable manner. At this special session we've got to galvanize the community, we've got to mobilize resources.
"The current focus on access to and the cost of drugs worries me, because I think the debate at the moment is simplistic and I think that some of the things that are being advocated could actually be distorting. We have to look at distribution systems. We have to look at health infrastructure, and we have to look at quality control. We have to make sure that there are continuing incentives for research."
Quality control is receiving increasing publicity from consumer groups in the developing world, especially in India where one major drug company, Cipla, has offered to sell antiretrovirals at a reduced cost and other drug companies are expected to follow. Although Cipla and other companies that export to the United States have been approved by the Food and Drug Administration, some other Indian manufacturers have been shown by local consumer groups to be selling substandard or even fraudulent drugs.
The problem is growing in developing countries, according to Jean- Yves Videau of the Centrale Humanitaire Medico-Pharmaceutique in Clermont-Ferrand, France, which promotes and monitors generic drugs. In a recent Bulletin of the World Health Organization, he wrote that hundreds of people die in poor countries from drugs produced for local markets that are contaminated, unstable or even toxic.
Timothy G. Evans, director of the health equity program at the Rockefeller Foundation and the convener of the experts' meeting in Kampala next month, agreed with Dr. Mugyenyi of the Ugandan research center that now is the time to draw on the experience Africans are amassing. He said that in particular they should address how Africans could cope with having only a small fraction of the money available to medical centers in the industrial nations.
"Africa needs to come up with its own solutions, its own methods," Dr. Evans said, adding that Africans could devise low-cost clinical methods for some processes that are conducted with expensive equipment elsewhere.
Dr. Mugyenyi said that in Kampala, African experts would ask the foundations and agencies how they could best help meet the African agenda. "This is our opportunity to get the priorities of H.I.V.-AIDS on the table and strongly recommend a way forward," he said. "We are looking for second-generation methods that would move the prevention and treatment of AIDS to a new level in Africa."