November 18, 2002
The problem of HIV drug accessibility for developing countries has been on the consciences of fair-minded people since the initial success of triple antiretroviral chemotherapy in 1996. In spite of this fact, relatively little progress has been made. For example, the total number of HIV-infected people who were treated with triple-drug regimens in all of Africa at the time of the Durban Conference in 2000 was estimated by UNAIDS to be only about 7,000. By the time of the Barcelona Conference in 2002, it is believed that this number had increased to about 50,000. Obviously, this is a lamentably slow rate of progress. Particularly when you consider that more than 28 million people in Africa are infected with HIV and over 20,000 people around the world die each day of HIV-related disease, and that between 2000 and 2002 alone the number of infected individuals in Africa increased by over 5 million.
In this talk, Dr. Elly Katabira stated his hope that the plight of people in resource-poor settings might soon change in regard to access to HIV drugs. This is due, in part, to the willingness of major pharmaceutical companies to accept the notion of dual pricing structures for their drugs, with these now being available in most African countries at near cost or at price reductions of over 90 percent in comparison to Western countries. In addition, the availability of generic products has also had significant impact in regard to drug availability. In many settings, the generically produced triple combination of 3TC (lamivudine, Epivir)/d4T (stavudine, Zerit)/nevirapine (NVP, Viramune) may now be available as a single pill, which may result in improved adherence to such a regimen. However, Dr. Katabira also pointed out that the patients he has treated tend to be at least as adherent to their antiretroviral therapy (ARV) regimens as those he has seen in the West, and he argued that the issue of adherence has been used for far too long as a false excuse to not provide drug access to HIV-infected individuals in Africa, India, and other developing country settings.
At the same time, Dr. Katabira pointed out that the needs of many African patients with HIV disease may be different than for patients in most affluent countries. First, the lack of available refrigeration and storage may often mitigate against the use of ritonavir-boosted PI regimens. Second, the frequent absence of a clean water supply may make the concept of once-daily (QD) dosing more important than in the West.
As stated, the combination of 3TC/d4T/NVP within a single tablet is appealing. At the same time, triple drug combinations of the type found in Trizivir (ZDV/3TC/ABC) may be too expensive, even at the reduced prices now available. The ability of some countries to produce generic drugs locally may be an important consideration both politically and in regard to capacity building.
Dr. Katabira also pointed out several of the unique features of HIV disease management in Africa. Among other considerations, most patients may only visit physicians or other caregivers at a time that they already have high viral loads and are immunosuppressed due to low CD4 counts. Many may need to first receive treatment and/or prophylaxis for opportunistic infections and/or tuberculosis. Problems of HIV drug interactions with anti-TB drugs are largely unique to developing countries and may cause delays in initiation of ARV therapy of six to eight weeks. The fact that many patients already have advanced disease at the time of presentation may also make it unlikely that they will achieve significant benefit from a first-line regimen such as 3TC/d4T/NVP, and other potential first-line alternatives may be too expensive.
This highlights the need to deliver the message that ARVs are becoming increasingly available in Africa, as this may encourage people to come forward earlier for serological testing and diagnosis than in the past. Dr. Katabira also highlighted the important findings from Uganda that successful treatment of HIV disease will lead to reduced viral loads and that this can play an important role in regard to a country's public health strategy, since a consequence may also be a diminished likelihood of transmission of HIV by treated individuals. Of course, the need for education and information campaigns also needs to be emphasized, and Dr. Katabira is proud of the fact that rates of new HIV infections in Uganda, although still substantial, have been greatly reduced in comparison with the situation of a decade ago.
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