Drugs alone no panacea

The debate on care and support for people living with HIV/AIDS in Africa is in danger of being hijacked by a single issue: access to antiretrovirals, the drugs that supress the growth of the virus. But, activists warn, in the developing world drugs alone are not a panacea. Serious questions must be addressed surrounding issues of poverty, the ability of governments to deliver on basic healthcare, and the capacity of doctors and nurses to administer effectively to those who are HIV-positive. "Even if the drugs can be made available you cannot take antiretrovials on an empty stomach," the national director of South Africa's National Association of People Living With AIDS, Nkululeko Nxesi, told IRIN. He said for his members the issues are about both living standards, and access to life-saving drugs. Multinational pharmaceutical companies and generic drug manufacturers are currently locked in a price war over the supply of antiretrovirals to developing countries that cannot afford Western prices for drug cocktails. In South Africa, the Pharmaceutical Manufacturers' Association - mostly subsidiaries of the drug majors - has taken the government to court in a high profile case that challenges its right to source low-cost generics. UNAIDS recommends triple therapy drugs as part of an "advanced package", the optimum in care and support treatments. By contrast, the bare minimum poor countries should implement include voluntary HIV counselling and testing, palliative care for the most common of opportunistic infections, and government backing for community-based initiatives. The intermediate stage goes further with TB campaigns, antifungals for systemic fungal infections, the treatment of Kaposi sarcoma and extensive herpes with drugs, and the surgical treatment of cervical cancer. UNAIDS in a June 2000 report on the global epidemic emphasised that progress in improving healthcare delivery "need not be strictly linear" - that countries need not wait to implement all the recommendations in each category before advancing to the next level of care and support. "The idea is you shouldn't be paralysed before you have all the right drugs for everybody. Before you jump to a broad national policy you can have pilot projects," in which more advanced treatments can be pioneered, a UN health official explained. "Not everybody is rural and impoverished in Africa." Antiretrovirals are notoriously difficult to take, and can be accompanied by side-effects. The capacity for large-scale testing and counselling that would precede their general availability, and the subsequent monitoring of patients once on the regimen does not exist in South Africa or any other African country. Nxesi acknowledges they are "not an absolute solution", but added simply: "For us, antiretrovirals are an imperative and necessary, as they are proved to extend life." "It's a no brainer to say that the health infrastructure is under enormous pressure already. It's an enormous task to even educate doctors (on triple therapy and counselling), let alone nurses," Dr James Macintyre of the HIV Research Unit at the Chris Hani Baragwanath hospital in Soweto told IRIN. "What we have to have in place is a mechanism for identifying HIV-positive people ... but where is the extra staff coming from? Where is the lab capacity going to come from?" He recommends a consensus on what constitutes appropriate care, a detailed and implementable government plan on tackling the challenges, followed by a phased introduction of treatment starting with the larger hospitals. As an indication of the problems that can be expected he pointed out that a limited government pilot project to provide Nevirapine to pregnant HIV-positive woman to block mother-to-child transmission is, six months later, still not up and running. "Right now we don't know what the difficulties will be," he said, "but if you could supply antiretrovirals tomorrow a lot of people could be reached." He added: "We can't assume that poor, less educated black people are going to be less able to use the drugs than a white middle-class person in San Francisco."