E-drug: Access to drugs for PLWHA. What about TB drugs and care?
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The World AIDS Conference in Durban is bound to kick up a lot of dust
concerning access to drugs for PLWHA. Not in the least because of the
dominating Western media which are looking for something "new" and
controversial to report. In practice this debate is likely to focus
pre-dominantly on access to anti-retroviral drugs.
As a TB control specialist in Africa for many years now I feel very
uncomfortable about this.
I agree that access to HIV/AIDS care in the less affluent countries
should ideally comprise the same interventions that we are able to
offer PLWHA in the affluent world. But I also find that this applies
to so many other diseases from which millions of Africans die every
year, not in the least tuberculosis.
AIDS activists appear to focus the discussion on access to care
entirely around the access to ARVD. Under strong pressure of AIDS
lobby groups 5 major drug companies have agreed that they will start
discussing large price reductions on ARVD for countries in
sub-Saharan Africa. Suppose this will bring the costs of an annual
course of ARVD to U$ 1,000 per person, instead of U$ 5,000- 10,000
now. So what?
There is a dangerous side to this debate. It is highly eliterian. It
foregoes the lack of access to low-cost high-quality primary health
care for millions of Africans, with or without HIV/AIDS. There are
few countries that can guarantee year-round access to high-quality
treatment and care of malaria, tuberculosis 2 other major killers on
the continent. The public health sector in Africa is still grossly
underfunded, whether governments and donors embark on health sector
reform, SWAps or not.
The focus on ARVD is therefore mainly an issue for the African elites
who have the ability to pay quality primary care services from the
well-equipped private-for-profit health sector. For the Africans who
are poor and largely dependent on the public health sector, access to
ARVD is not an issue, rather a bad dream. They will never be able to
afford it from their pocket, and the public sector could easily spend
all its budget on ARVD and the need would still not be satisfied. I
hope therefore that African Governments will be wise enough not to
spend a penny of public funds on ARVD even if they costs just U$
1,000 per year, before they have addressed effectively the issues of
primary HIV prevention and care, and primary health care in general.
Such a decision would detract funds from very basic interventions
such as safe motherhood, vaccinations, tuberculosis, malaria, STD
etc. and would introduce enormous inequity into the basic health care
system.
AIDS activism should give more attention for the basic needs of PLWHA
in Africa who are poor. Killer no.1 among PLWHA is tuberculosis, of
which one highly effective treatment course is available for just U$
30. Many PLWHA in Africa will develop tuberculosis as the first
opportunistic disease. In some countries in SSA more than 50% of
tuberculosis patients are HIV positive (up to 70% in Malawi). This
has made AIDS and tuberculosis synonymous for most communities, and
"TB" has become an attractive euphemism for AIDS.
Yet many millions of Africans with and without HIV do not have access
to these drugs and the required care that goes with it (the DOTS
strategy), because their Governments do not see TB as a priority.
Access to high-quality tuberculosis care deserves more attention from
African AIDS activism. It is clearly highly effective, feasible and
affordable, improves quality of life and life-expectancy of PLWHA
significantly. It also prevents transmission of tuberculosis
infection to their close relatives and beloved ones, particularly
those who are most susceptible to TB disease, those who are also HIV
positive.
Access to treatment of other opportunistic infections is also
scattered and largely unavailable. Recently UNAIDS announced that
preventive treatment with co-trimoxazole is likely to be highly
effective in SSA to prevent OI's among PLWHA. Yet this simple and
cheap drug is often not even accessible for the treatment of the most
simple upper and lower respiratory infections. It is clear that the
operationalisation of this recommendation of UNAIDS can only take
place when the broad need for co-trimoxazol is addressed in the PHC
setting.
It also requires wide-spread access to HIV counselling and testing to
identify those who will benefit from preventive treatment. Yet in
most African countries this service is largely unavailable. In many
countries even safe blood is still a dream.
There is another danger. If price reductions make ARVD accessible for
the affluent classes who are also the decision makers, it is likely
to decrease their interest for HIV prevention. The ruling elites may
consider HIV/AIDS now a "curable disease", or a "chronic disease",
and providing them with the perfect excuse to neglect primary HIV
prevention and care for PLWHA.
I call on AIDS activists in Durban not to just focus on ARVD. Primary
HIV prevention and care for PLWHA must be and remain the priority for
the future. It has been grossly neglected with only Senegal and
Uganda able to show good practice in this respect.
I would certainly welcome that AIDS activists emphasise the access to
tuberculosis care and support as one of the priorities for PLWHA in
Africa.
Jeroen van Gorkom
Tuberculosis Consultant
Royal Netherlands Tuberculosis Association (KNCV)
[The issues raised here have been raised before and I hope they
receive appropriate attention, especially during the debates that
will be part of the Durban conference.
A feature of the MSF campaign is the call for access to appropriate
TB treatment as a priority and for more R&D into TB drugs aiming for
a shorter effective, affordable course of treatment. BS Co-moderator]
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