E-drug: WHO and ARV access (cont'd)
---------------------------------------------
[Recently Hilbrand Haak responded to Peter Burgess' comments
on WHO's efforts to improve access to TB drugs through its GDF.
Another response to Peter was posted on Afro-nets - crossposted here
with thanks. I have added some more comments at the base of the
message BS.]
I have been following the discussion on AFRO-NETS and around us about
antiretroviral treatment (ART) with concern. Peter Burgess is "terri-
bly sceptical". I don't know what that makes me, maybe overwhelmingly
sceptical. In the discussion of access to ART I haven't really seen
any discussion about anything else but the cost of the medication /
medicines itself. I think that most of the countries in desperate
need for ART for their people can not afford ART even if the antiret-
rovirals are free. I really think that we should start to discuss
about these problems and try to find solutions.
To treat people with HIV we have to test them first. For testing we
need trained counsellors (for pre- and post-test counselling as well
as continuous counselling). Training costs quite a lot and we need
many many counsellors. The counsellors need to be employed. To treat
people with HIV we need also to train doctors and nurses. Treatment
is not simple, one protocol is good for one person, the other for the
other one. Side-effects of the treatment may force the medication to
be changed. This should only be done by a well trained health profes-
sional. In quite many counties there is lack of health professionals,
so if we put doctors and nurses in charge of HIV-treatment, it might
be difficult to find people to take care of their previous duties.
We have to identify people in need of medication. This could be done
with CD4-cell counts (laboratory tests) or with clinical evaluation.
Both of these methods are costly and have to be repeated about every
6 months.
People with ART need regular controls and also some regular blood
tests.
If a person gets side-effects of the medication and lives for example
20 kilometres from the clinic, do we really believe that (s)he will
walk to the clinic (when sick with diarrhoea for instance) and ask
for some other kind of medication? Most probably (s)he will just stop
the medication.
Very many - if not most - of the people with HIV are quite poorly
educated or illiterate. If the treatment regimen is in any way com-
plicated (for instance one medicine should be taken twice daily and
another one every 8 hours), this might be too difficult to carry out.
And we are talking about medication for the rest of the person's
life...
Poverty is one of the main reasons HIV is so prevalent in Southern
Africa for example. Poverty is also one of the reasons why implement-
ing ART might be very difficult. Let's assume that I am infected with
HIV, my husband has left me and I live in a rural area in Namibia
without any work which I would get paid for. If I get ART for one or
two weeks and my children do not have food, I would most probably
sell the medicine and buy food for my children. Also side-effects of
the medication are more likely if I do not have proper food.
So, in my opinion the problems with ART are partly problems with the
cost of the treatment (including training and employing counsellors,
training and possible relocation of nurses and doctors, cost of HIV-
tests, cost of CD4-cell counts and other laboratory tests, cost of
medicines) and partly problems with adherence to the treatment (dif-
ficult treatment protocols, side-effects, poverty) which create a
substantial risk of short and ineffective treatment and thus a real
risk of creating resistance.
I think that ignoring these problems and only concentrating on the
price of the medicines gets us nowhere. When the medicines finally
are affordable, we won't have the strategy to ensure that people in
need get them.
Sincerely,
Maija Palander
Medical Doctor, Project Manager
Windhoek, Namibia
Tel: +264-61-257-231
Fax: +264-61-257-216
mailto:maija.palander@fimnet.fi
Moderator's comment
I think we have become much more aware of the issues mentioned by
Maijia and the need for comprehensive programs before provision of
treatment with ARV drugs can even be considered. For example, MSF
has been implementing successful comprehensive pilot treatment
programs in several countries.
I would like to refer people to the Khayelitsha program described in
the latest edition of the Essential Drugs Monitor as an example of
how the important issues mentioned above are addressed.
http://www.who.int/medicines/mon/32_11.pdf
That is not the only example but the report is very succinct. The
MSF programs in Thailand, Kenya and other countries are all run along
the same lines. Patients must be admitted to the program. Counsellors
are in place.
Follow-up is available etc. As well as clinical criteria for
admission to the program there are social criteria - patients must
have not missed an appointment for 4 months and have complied totally
with treatment for opportunistic infections. In addition they must
identify one person they disclose to for support. That person is
trained. It maybe a family member or not. That person helps support
the person's treatment and provides support for any problems or for
referral to the clinicians for clinical problems. This might sound
like discrimination. You would not demand all that for admission to
treatment for diabetes. But in this case success of treatment is so
crucial that I think it is justified.
A complete report of the Khayelitsha program will be released soon
and we will make it available.
The treatment programs run by companies such as Heineken are similar
and the DFID policy also covers those issues. Care of families and
criteria for lifelong support are built into the policies.
By the way, low cost appropriate technology CD4 tests and training
are being provided in many countries. These tests rely on humans and
buckets rather than a lot of hightech electronic equipment and
computers. Comparison studies have checked that the results
correlate well with the results obtained by the hightech methods and
they do. Test are around $6 each at the moment and price is less for
bulk orders. Prices are likely to reduce more anyway.
The Haiti program described by Paul Farmer et al in Lancet Vole 358
Aug 4, 2001- 'Community based approaches to HIV treatment in
resource-poor settings' - relies on clinical criteria rather than lab
criteria for admission to the treatment program.
If people would like more information about the programs I have
mentioned please contact me (NOT E-Drug).
best wishes
Beverley Snell
e-drug moderator
email <bev@burnet.edu.au>
Access Essential Drugs Monitor #32 at http://www.who.int/medicines/mon/mon32.shtml
--
To send a message to E-Drug, write to: e-drug@healthnet.org
To subscribe or unsubscribe, write to: majordomo@healthnet.org
in the body of the message type: subscribe e-drug OR unsubscribe e-drug
To contact a person, send a message to: e-drug-help@healthnet.org
Information and archives: http://www.essentialdrugs.org/edrug