E-drug: Antiretrovirals and AIDS in South Africa
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Dear E-druggers,
I would consider the below editorial on cheaper antiretrovirals in South
Africa as important reading for everyone interested in this debate.
Distributed as fair use.
Hilbrand Haak
E-drug co-moderator
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BMJ 2000;320:1551-1552 (10 June 2000)
Editorial
Cheaper antiretrovirals to treat AIDS in South Africa
They are at their most cost effective in preventing mother to child
transmission.
Many countries in sub-Saharan Africa are overwhelmed by a pandemic
of HIV and AIDS that is reducing life expectancy by two decades,
reversing gains made in infant mortality and increasing the burden on
health resources that are already overstretched. South Africa is no
exception. The government, AIDS activists, healthcare professionals,
and communities are desperate to find a universal solution or "magic
bullet." Triple combination therapy has dramatically widened the gulf
in people's experience of HIV and AIDS, depending on whether they
live in the North or the South. Not surprisingly, activists, both local
and international, have persistently called for a substantial lowering of
the prices of antiretroviral and other expensive drugs needed to treat
people with AIDS.
What would reducing the price of antiretrovirals mean for South Africa
in its battle against HIV and AIDS? It is important to distinguish
between using antiretroviral drugs to prevent mother to child
transmission and to treat adults infected with HIV. Interventions to
reduce vertical transmission are highly effective in preventing primary
HIV infection in babies and would probably save at least 15 000 lives
per year in South Africa(1,2). The costs of such programmes are
located in the setting up of accessible antenatal services, counselling
and testing, and training of staff.3 Drawing on cost data from
previously published work, we have calculated that the antiretroviral
component would constitute only an estimated 7% of the total costs
of setting up a programme in South Africa to prevent vertical
transmission based on using nevirapine(3). The entire programme
would cost less than 1% of current spending on public health care.
Even at current market prices, therefore, this seems a highly cost
effective intervention in South Africa and elsewhere(3,4). There is
widespread support within the healthcare community in South Africa
for piloting these interventions as soon as possible(5).
It is more difficult to promote the case for antiretroviral medication to
adults with HIV. Here drugs are a major component of the cost, since
high doses are given indefinitely to patients. Even though some
savings would be made in preventing admission to hospital, this
intervention is unlikely to pay for itself. If the costs of triple
antiretroviral therapy were reduced to one quarter of current levels,
this would still require a more than 50% real increase in the public
health budget by 2010(6). Glaxo Wellcome's recently announced
proposal to reduce the price of the combination drug Combivir (fixed
dose combination of zidovudine and lamivudine) to $700 (��440) per
year will no doubt increase the market for antiretrovirals in South
Africa. It would make little difference to most poor people, however,
who rely on the state healthcare system with budget constraints too
tight to accommodate more than marginal extra costs. Furthermore,
for the public sector there would seem to be more pressing priorities in
terms of HIV care. Isoniazid and co-trimoxazole prophylaxis against
tuberculosis and pneumonia respectively has been shown to be highly
effective but is rarely used outside of specialist care centres in South
Africa(7,8).
Cure rates of tuberculosis are poor even by the standards of
developing countries (57% for patients with newly positive smears)
and the whole infrastructure for treatment needs substantial
overhaul(9). Drugs such as fluconazole and ganciclovir for the
management of severe opportunistic infections remain inaccessible to
most South Africans. Finally, to take advantage of accessible
antiretroviral drugs, people need to be comfortable with finding out
and declaring their HIV status; most evidence shows this is not yet
the case.
In common with many developing and developed countries, South
Africa has tried to implement policies such as parallel importation and
compulsory licenses, which would reduce drug prices generally.10
However, the issue of affordable drugs has been complicated by a
somewhat inexplicable position on drugs for HIV and AIDS
specifically, originating in President Mbeki's office. The South African
government seems ill disposed to the use of antiretrovirals for any
purpose. The reasons given are not currently cost concerns, but rather
doubts about the safety and efficacy of antiretroviral drugs, and even
doubts about the scientific basis of AIDS causation and treatment.
This is shown by the invitation to Peter Duesberg, who is known as
an AIDS dissident, to sit on a government advisory panel in South
Africa. The rather controversial approach is somewhat difficult to
understand but may be located in a need to find a unique `African'
solution to the problem of HIV and AIDS.
The government is probably right about the secondary importance of
antiretrovirals, but for the wrong reasons. Real solutions to the AIDS
epidemic in South Africa are a lot less glamorous. They consist of
incremental improvement in basic health services, including antenatal
care, prophylaxis and treatment of opportunistic infections, and
tuberculosis and sexually transmitted disease care, improved status
for women in society, support to community based palliative care
providers, and improved cooperation between government and
non-governmental organisations. Lowering the price of antiretrovirals
has a role to play, but is not in itself a solution.
Karen Zwi, senior lecturer.
Division of Community Paediatrics, University of the Witwatersrand
Neil S�derlund, senior researcher.
Centre for Health Policy, University of the Witwatersrand
Helen Schneider, director.
Centre for Health Policy, PO Box 1038, Johannesburg 2000, South
Africa
1. Dabis F, Msellati P, Meda N, Welffens-Ekra C, You B, Manigart O,
et al. 6-month efficacy, tolerance and acceptability of a short regimen
of oral zidovudine to reduce vertical transmission of HIV in breastfed
children in C�te d'Ivoire and Burkina Faso: a double blind
placebo-controlled multicentre trial. Lancet 1999; 353: 786-792.
2. Guay LA, Musoke P, Fleming T, Bagenda D, Allen M, Nakabiito C,
Sherman J, et al. Intrapartum and neonatal single-dose nevirapine
compared with zidovudine for prevention of mother to child
transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised
trial. Lancet 1999; 354: 795-804.
3. S�derlund N, Zwi K, Kinghorn A, Gray G. Prevention of vertical
transmission of HIV: an analysis of cost effectiveness options
available in South Africa. BMJ 1999; 318: 1650-1656.
4. Marseilles E, Kahn JG, Mmiro F, Guay L, Musoke P, Fowler MG, et
al. Cost effectiveness of a single-dose nevirapine regimen for mothers
and babies to decrease vertical HIV transmission in sub-Saharan
Africa. Lancet 1999; 354: 803-809.
5. Bolton KD, Hofmeyr GJ. Reducing mother-to-child transmission of
HIV. S Afr Med J 2000; 90: 323-324.
6. Forsythe S. The affordability of antiretroviral therapy in developing
countries: what policymakers need to know. AIDS 1998; 12:
S11-S18.
7. Wilkinson D, Squire B, Garner P. Effect of preventive treatment for
tuberculosis in adults infected with HIV: systematic review of
randomised placebo controlled trials. BMJ 1998; 317: 625-629.
8. Wiktor SZ, Sassan-Morokro M, Grant AD, Abouya L, Karon JM,
Maurice C, et al. Efficacy of trimethoprim-sulphamethoxazole
prophylaxis to decrease morbidity and mortality in HIV-infected
patients with tuberculosis in Abidjan, C�te d'Ivoire: a randomised
controlled trial. Lancet 1999; 353: 1469-1475.
9. Bamford L. Tuberculosis. In: Crisp N, Ntuli A, eds. South African
Health Review 1999. Durban: Health Systems Trust, 1999.
10. Medicines and Related Substances Control Amendment Act, Act
90 of 1997. Pretoria: Government Gazette, 1997.
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