Doctors demand immediate access to antiretroviral drugs in Africa

BMJ 2001; 322 doi: (Published 28 April 2001) Cite this as: BMJ 2001;322:1018
  1. Annabel Ferriman
  1. Kampala

    Sub-Saharan Africa is bound to become the biggest user of antiretroviral drugs in the world, so it has to start preparing to use them now, a conference of AIDS experts was told last week.

    More than 25 million people in the region are HIV positive, out of a total of 36 million worldwide, yet only a few thousand are being treated with antiretroviral drugs. These drugs could turn AIDS in Africa into a treatable, though chronic, disease, as they have done in the United States, Europe, and Australia, the conference heard.

    Dr Peter Mugyenyi, director of the Joint Clinical Research Centre in Kampala, Uganda, told the conference, hosted by the centre and convened by the Rockefeller Foundation, that there was “moral outrage” over the continued loss of prime life in Africa when effective drugs existed and were cheap to manufacture.

    “Be conscious of the deadly high cost of delay, and act now,” Dr Mugyenyi said. “Three million people died last year alone, of which an estimated 2.4 million were Africans. That is the equivalent of the populations of Botswana and Swaziland put together,” he told the 200 participants, who were drawn from academia, technical agencies such as the World Health Organization (WHO) and the National Institutes of Health, donor foundations, and non-governmental organisations.

    Dr Mugyenyi said that people put forward many reasons why antiretroviral drugs should not be used in Africa, but these were mostly excuses. Some people said that they were too complicated to be used, but doctors in Africa had been handling complicated cancer drugs for years, and these were just as dangerous in the wrong hands. Some people claimed that prevention was better than cure, but what they meant was that prevention was cheaper than cure.

    Although Uganda had reduced the prevalence of AIDS from 16% in 1990 to 8% in 1999, through strong measures and good leadership, there were still one million infected people in Uganda, and 110 000 people became infected in 1999 alone. “The current HIV rate is still unacceptably high and appalling,” he added.

    The president of Uganda, Yoweri Kaguta Museveni, who addressed the meeting, said that Uganda had achieved its success by understanding its people and adopting a mass approach. The government had spread its message through political and local council meetings, primary schools, and the radio—putting out broadcasts in local languages, not just in English.

    But he said that it would be wrong to expect pharmaceutical companies to provide antiretroviral drugs either free or at greatly reduced prices. “They are in the business of making drugs for profit. They are not philanthropists,” he declared. He wanted to see a scheme whereby drug companies were asked how much it had cost to develop a drug. Then they could be paid off and the drug made available at low price so that they could be widely used.

    Other participants expressed scepticism about the relevance of antiretroviral therapy to Africa, however. Dr Adetokunbo Lucas, of the Global Forum for Health Research, Geneva, said: “We have to beware of the problems that can arise. There might be a danger that by spending money on treatment, money might be diverted from prevention.

    “It might divert attention from existing programmes, such as the malaria and immunisation programmes.” He pointed out that between 1995 and 1998 vaccination against tuberculosis in Africa fell, as did vaccination against diphtheria, tetanus, and poliomyelitis. “It was not the cost of the vaccines but the weakness of our health systems, which are very fragile,” he said.

    Julian Lambert of the UK Department for International Development said that if money was spent on these expensive drugs, other programmes would suffer. “The cost implications are huge. Something is going to have to go.”

    Several participants pointed out that the cost of the drugs was not the only problem. The cost of monitoring their use and the lack of infrastructure for administering them were also major problems.

    Eric Goemaere of Médecins Sans Frontières in Cape Town said that antiretroviral drugs should be made available to patients in sub-Saharan Africa (and in fact were already being prescribed by doctors in his locality to those who could afford them), but if they were going to be made available to poor and destitute patients, rather than just the wealthy patients, a strong campaigning movement would be needed. Even if the costs of the drugs were to drop still further to $200 (£133) a year, international funding was still needed.

    “We want to give priority to the poor and destitute, but we know that if people are too isolated and poor, they will not take the treatment properly. So we have a lot to learn,” he added.

    A new approach to treating HIV and AIDS at a local, primary care level was outlined by Dr Mario Raviglione of the WHO. The approach, known as syndromic management, was geared to the fact that 95% of those who were HIV positive in Africa were unaware of their status, and so when they became ill they presented to a primary care health worker, not to an AIDS clinic. There were no doctors or laboratories at primary care level so health workers needed guidelines for treating people who had symptoms but who were untested.

    The approach is designed to reduce AIDS mortality through better basic medical care. It is also expected to lead to standardisation of treatment and referral, rationalisation of drug use, and case management at an appropriate level of care. Syndromes will be defined according to symptoms, and the main syndromes are likely to be grouped around respiratory tract infection, skin ailments, sexually transmitted disease, febrile illness, and chronic diarrhoea.

    Dr John Walley of the Nuffield Institute for Health, Leeds, said that guidelines for the different syndromes would be developed by subgroups of clinicians, under the direction of a WHO working group, and would be subject to field tests at the draft stage.

    In drawing up guidelines, the groups are expected to draw on lessons from an earlier collaborative venture in which experts from WHO, Unicef, and the World Bank had produced a unified approach to treating sick children in developing countries. It was known as the integrated management of childhood illness (IMCI) initiative and is, to date, the most evolved integrated primary care strategy to use syndromic management.

    The guidelines would include how to assess and classify presenting symptoms; treat the acute problems; teach about treatment and arrange follow up; assess HIV status and awareness; and counsel and educate about continuing care and home care.

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