San Francisco Examiner - July 11, 2000
Ulysses Torassa, Examiner Medical Writer

South African judge and AIDS activist Edwin Cameron drew a standing ovation Monday at the 13th International AIDS Conference as he lashed out at the government and drug companies for not doing more to put anti-retroviral drugs within reach of the vast majority of HIV-infected people, who live in developing nations.

Cameron, who is white and HIV-positive, can afford $400 a month for the drug cocktails that have kept him in robust health.

"I am here because I can afford to pay for life itself," Cameron said. Elsewhere in Africa, he said, people are "dying by the tens of millions."

"The treatment that can save them exists," he said. "What is needed is only that it be made accessible to them."

But in other quarters of the conference, scientists were more cautious about introducing the drugs, and not only because they are so expensive.

Last week, a German pharmaceutical company, Boehringer Ingelheim, said it would provide free nevirapine for pregnant mothers to reduce transmission to their babies.

And Merck announced Monday a partnership with the Bill and Melinda Gates Foundation to provide $100 million, part of it for anti-virals, to fight HIV in Botswana.

Other large drug companies are expected to announce similar initiatives this week.

Rapid mutations

At the same time, ample evidence from the United States and Europe has demonstrated the vexing ability of HIV to mutate rapidly if intensive drug therapy is not rigidly maintained.

"I am concerned if the countries start using sub-optimal regimens, you will see very rapid emergence of drug resistance," said Douglas L. Mayers, an AIDS doctor and researcher from the Henry Ford Hospital in Detroit. "There is real concern (because) these are transmissible viruses."

Indeed, a few trials of anti-retroviral drugs in Africa are producing hints that resistance has become an issue and that a significant number of people are not able to tolerate the therapy's side effects and drop out or miss doses.

Some proponents of bringing drug therapy to developing countries have suggested using less complicated - and less powerful - treatments as a way to make therapy more workable.

But Mayers said that was the wrong way to go. "That's the ideal circumstance to create multi-drug resistance," he said.

He doesn't believe the drugs should be kept from developing countries, but said that if they were made available, it should be hand-in-hand with programs to ensure safe sex practices so that whatever resistant viruses emerged were not unleashed into the general population.

Multi-resistant viruses

Already, Mayers said, some U.S. cities are seeing multi-drug-resistant viruses in 16 to 25 percent of patients.

"We have to have that same message for the United States, too," he said. Putting the health structure in place to administer and monitor the complicated drug regimes also will be expensive and difficult, and could divert resources from other efforts to fight the epidemic, said Roy Mugerwa, a Ugandan AIDS researcher.

Developing countries have 15 to 75 doctors per 100,000 people, while that figure is 200 to 750 in the industrialized world, Mugerwa said.

Many doctors and health care workers in southern Africa have died or are sick with AIDS.

Mugerwa estimates the cost of treating someone with HIV without anti-retroviral therapy in a developing country is about $490 a year, compared with about $8,000 for someone getting anti-retrovirals, much of which comes from the cost of visits, counseling, monitoring and tests, as well as drugs. At the same time, he said, the per capita gross national product of Uganda is $350, and in most developing countries just $20 per person per year is spent on health care. That compares to $500 per capita in Western nations.

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