E-DRUG: Africans Outdo Americans in Following AIDS Therapy
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[Finally, some evidence to throw out a racist prejudice (that Africans
cannot take pills on time) - copied as fair use from the NY Times. WB]
Africans Outdo Americans in Following AIDS Therapy
New York Times, September 3, 2003, By DONALD G. McNEIL Jr.
Contradicting long-held prejudices that have clouded the
campaign to bring AIDS drugs to millions of people in
Africa, evidence is emerging that AIDS patients there are
better at following their pill regimens than Americans are.
Some doctors, politicians and pharmaceutical executives
have argued that it is unsafe to send millions of doses of
antiretroviral drugs to Africa, for fear that incomplete
pill-taking will speed the mutation of drug-resistant
strains that could spread around the world.
The danger already exists: nearly 10 percent of all new
H.I.V. infections in Europe are resistant to at least one
drug.
For Africa, the issue is particularly touchy because it is
tinged with racism. In 2001, for example there was an
outcry when the director of the United States Agency for
International Development said that AIDS drugs "wouldn't
work" in Africa because many Africans don't use clocks and
"don't know what Western time is."
Now surveys done in Botswana, Uganda, Senegal and South
Africa have found that on average, AIDS patients take about
90 percent of their medicine. The average figure in the
United States is 70 percent, and it is worse among
subgroups like the homeless and drug abusers.
Compliance has become easier because drugmakers from India
and elsewhere are beginning to make triple-therapy
cocktails that come in as few as two pills a day. (These
are not available in the United States yet because of
patent problems - no Western company makes all three drugs
for an ideal cocktail.)
After nearly a decade of watching Africans die because AIDS
drugs cost $10,000 or more a year per patient, rich nations
began pledging aid after generic competition in 2001 drove
prices down to about $300 a year. Last week the World Trade
Organization agreed to alter its rules to give poor nations
more access to life saving medicines.
But as with any epidemic moving through a poor and
ill-educated populace, the threat of disaster clings like a
shroud. Patients in badly supervised programs have been
caught selling pills or sharing with desperate relatives -
acts of greed or mercy that could lead to doomsday strains
of the virus.
Anti-retroviral therapy "is the No. 1 priority for the
developing world," said Robert C. Gallo, director of the
Institute for Human Virology and a pioneer in researching
H.I.V., the virus that causes AIDS. "But it will be a
tragic mistake if it's not done right. You'll have
`Eureka!' and `Thank you, America!' for two or three years
- but then you'll get multi-drug resistance, and whoops. .
. ."
Drug-resistant strains are inevitable, doctors say, and
turn up in every illness from malaria in Africa to
children's ear infections in Manhattan. Hard-to-cure
variants evolve spontaneously in response to drugs. But
they are more likely to grow and be passed on if patients
skip doses, because triple therapy often suppresses even
mutant strains. To avoid an epidemic of incurable AIDS, new
drugs must be discovered faster than old ones become
useless.
Africa can still do better than the West, they say, by
avoiding old mistakes. Today's drugs are more potent and no
one will spend years on one drug, thereby breeding
resistance, as many Westerners did on AZT before triple
therapy emerged in 1996.
Moreover, doctors say, most African patients are zealous
about their regimens. They are also more truthful when
estimating their adherence, said Dr. David Bangsberg, a
professor of medicine at the University of California in
San Francisco who has studied compliance patterns here and
abroad.
On average, he said, American patients tell their doctors
that they are doing 20 percentage points better than they
really are - that is, a patient who says he takes 90
percent of his pills will, when tested with unannounced
home pill counts or electronic pill-bottle caps, turn out
to be taking 70 percent.
A study of 29 Ugandan patients found that, on average, they
estimated that they were taking 93 percent of pills and
proved to be taking 91 percent.
Though poor, more than 80 percent of the Ugandans had jobs,
though most earned less than $50 a month. Most were women
in their 30's, and paying $27 a month for their
twice-a-day, three-drugs-in-one pill called Triomune, made
by Cipla Ltd. of Bombay.
In many such cases, explained Dr. Merle A. Sande, a
University of Utah medical school professor who also works
in Uganda, the whole extended family, possibly with several
infected members, will chip in so that one member will be
saved to care for the children.
"If the whole family is pooling its resources to pay for
you," he said, "you damn well better take your drugs.
"That's a whole different scenario from the U.S., where
patients get free medicine, and if they change therapy,
will let a month's worth go to waste."
Several doctors in Africa said their patients were highly
motivated because they had seen friends or family die. Most
come in only when deathly ill, so the drugs seem to perform
a miracle, making them well enough to go back to work. And
even $1 a day is a lot, so they treat it as "an
investment," said Dr. Elly Katabira of Makerere University
Medical School in Uganda.
In Botswana, with the world's highest infection rate, pill
counts on 400 of the 10,000 patients on therapy showed that
85 percent were taking their pills flawlessly, said Dr.
Ernest Darkoh, the national program manager. "If you loosen
the criteria a little - missing a dose by two hours, for
example - you get about 90 percent," he added.
There are a few exceptions, he admitted: "Some people bring
back their pill containers saying, `Thank you, but my
traditional healer told me not to take these.' "
However, some programs are not as good as others.
In Nigeria, Africa's most populous country, an ambitious,
widely praised plan to get generic drugs to 15,000 citizens
has been hampered by bureaucracy, corruption and a scarcity
of laboratories.
Dr. Ernest Ekong, an AIDS specialist at the Military
Reference Hospital in Lagos who has made Nigeria's case at
international conferences, at first said adherence so far
has been "no problem." Then he began to qualify that.
Some patients, he said, have felt so well that they shared
pills with friends who could afford the $10 monthly charge.
Some who developed "nevirapine rash," or nerve tingling,
cut back.
"And," he admitted, "a very small percentage are selling
their drugs."
Non-adherence, he said, is worst among patients with
co-infections that require more pills - tuberculosis
patients, for example, must also take four antibiotics.
No formal resistance study has been done, but Nigerian
doctors are worried about a few patients who are taking all
their pills but not getting better - a sign that they might
have resistant strains.
The best adherence seems to come under tight supervision.
A recent study in Cape Town found that older patients,
patients who took pills twice a day instead of three times,
and patients who spoke the same language as clinic staff
members tended to do best.
In May 2001, Africa's best-known pilot project was opened
by Doctors Without Borders in a crowded, dirt-poor black
township near Cape Town called Khayelitsha.
Because the drugs were then scarce, the charity set high
hurdles for patients, so high that only 550 of the clinic's
5,000 visitors are taking medication now. It reports
extraordinarily high levels of compliance.
Pill counts by social workers show that, after six months
on treatment, 96 percent of the patients are still taking
95 percent of their pills.
As a surer but more expensive backup, blood tests see how
many have minuscule levels of virus, an indication that
they have faithfully taken their pills.
After six months, 91 percent do; at 18 months, 83 percent
do.
"That's pretty good," said Dr. Eric Goemaere, the program's
director. "Certainly better than what you see in most North
American studies."
To qualify for treatment, patients must give up all alcohol
and drugs; complete three months of taking a simple
antibiotic; be on time for four clinic appointments in a
row; reveal to their families that they are H.I.V.
positive; and choose a friend who must come to counseling,
make sure all pills are taken and report problems to a
nurse.
Dr. Bangsberg expressed surprise at how demanding the
clinic was.
"Imagine trying to impose the no-drinking rule in San
Francisco," he said.
Such standards are tough but necessary, Dr. Goemaere said.
Binge drinking is the norm in South African townships, he
said, and studies show that patients with histories of
alcohol abuse or depression are the worst at taking their
pills.
"There are certainly parts of Africa where you wouldn't
want to try this - in Congo, for example," he said. "But 65
percent of South Africa is urbanized. People know how to
take a taxi and get to an appointment - and how to take
their pills."
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