Tests Offer New Hope On AIDS In Africa
Washington Post, Wednesday, July 12, 2000
By David Brown
DURBAN, South Africa, July 11 –– Results of three small experiments in Africa, made public today, raised hopes that state-of-the-art AIDS treatments now available only in the world's richest countries might prove usable for larger, poorer AIDS-infected populations in many cities of the Third World.
Most prominent Western AIDS specialists have argued that the antiviral drug treatments require too much logistical support for rudimentary health systems in poor countries. But researchers reported significant successes in administering the sophisticated "combination therapies" in the capitals of Ivory Coast, Senegal and Uganda.
The studies, presented at the global AIDS conference here, involved fewer than 1,000 of the 24.5 million Africans infected with the AIDS virus. But by suggesting that logistical barriers might be overcome in some cases, they appeared likely to increase pressures on drug makers to cut prices drastically in the developing world for sophisticated anti-AIDS drugs.
The therapies, which use various combinations of antiviral drugs, emerged in Western countries five years ago, transforming the health and futures of AIDS patients who took them. Since then, the gulf in medical care between rich and poor countries has grown uncomfortably--many believe shamefully--wide.
A near consensus of AIDS policymakers in the West has said combination therapies would be impractical in Africa, even if funding were made available. Such therapies require patients to have ready access to their doctors, to sophisticated laboratory testing and to social services. In much of Africa, patients lack reliable transportation, sufficient nutrition and even clean water.
But the findings presented here revise that view, while underscoring the degree to which the high cost of drugs is an obstacle to treatment. The use of combination therapies in Ivory Coast and Uganda "was definitely a curiosity when it started," said Peter
Piot, director of UNAIDS, the United Nations agency running the tests. "But it is going to be much more useful than I thought at the time. What we really wanted to do was break that front of nihilism."
In the Ugandan project, 350 people took one-or two-drug therapies at a subsidized cost of about $250 a month. After 15 months, 54 percent were still on the treatment--less than in most clinical experiments in the West, but a lower attrition rate than some had predicted. Twenty-one percent had dropped out, and "the main reason was affordability," said Raymond Mwebaze, a physician who helped run the project.
In Ivory Coast, 422 people took combinations of drugs whose prices, like those in Uganda, had been reduced through negotiation between UNAIDS and the drug companies. The government provided additional subsidies for some patients, and a year and a half into the program, 71 percent of the patients were still taking the drugs. In a home-grown project in Senegal for 75 patients, nearly 90 percent were still enrolled after two years.
Mortality was relatively high in the programs--17 percent in Uganda--because most patients had advanced cases of AIDS when they enrolled. Successful treatments, in which the virus was fully suppressed in patients' bloodstreams, were relatively few, largely because many people were being treated with two drugs, rather than three. The virus was suppressed among 52 percent of Ivorians who received three drugs.
In a substantial number of cases, the virus resisted treatment because patients had previously taken inadequate courses of antiviral drugs. None of those drawbacks, however, is different from what occurred when combination treatment was first introduced to AIDS patients in the United States and Europe.
The conference has been buzzing with talk of "access to treatment"--and this usually means access to antiviral drugs. More than in previous biennial world AIDS conferences, this one is hosting sessions on nonmedical topics, such as patent protection.
Delegates also are focusing on mechanisms by which developing countries can legally wrest the right to produce or acquire generic versions of expensive drugs.
The theme is even surfacing in otherwise strictly scientific presentations. On Monday, Anthony S. Fauci, head of the National
Institute of Allergy and Infectious Diseases, told several thousand delegates about research suggesting that well-timed interruptions of triple-drug therapy might help patients as much as the fastidious and constant therapy that is now the norm. "I think it will have implications to countries that cannot afford the kind of continuous, vigorous therapy that we're talking about," he said.
There also has been much discussion about whether improvement in health systems, such as the building of laboratories and clinics and the training of clinicians, should precede sophisticated AIDS treatments.
What is becoming clear, however, is that programs have a way of instantly creating both demand and capacity once they are launched--a situation one expert described as "building the ship while it's sailing." "The availability of treatment completely changes the dynamics," said Daniel Berman, a project coordinator in Geneva with the medical aid group Doctors Without
The companies that manufacture AIDS drugs--always a major presence at these meetings--are trying to steer the conversation away from drug prices and especially from the question of how deeply they have promised to cut them.
"Price is only one part of the problem; the real question is how to increase access," Jeffrey L. Sturchio, a Merck & Co. executive, said earlier this week in announcing his firm would donate $50 million to the government of Botswana over five years to "fundamentally strengthen its primary health-care system."
© 2000 The Washington Post Company