The Miami Herald, Inc.; a Knight Ridder publication. One Herald Plaza, Miami, FL 33132-1693 - Monday, October 28, 1996 Edition: Final Section: Front Page: 1A Word Count: 1,177
Katherine Ellison, Herald Staff Writer

The AIDS "cocktail," a mix of medications hailed by many patients as the most promising development to date, can cost a patient as much as $12,000 a year -- a major issue in the United States, where the AIDS activist group ACT UP has plastered pharmacies with stickers condemning the drug manufacturers as "AIDS profiteers."

Brazil's government has vowed to spend up to $45 million over the next year to make available the new protease inhibitors that are key ingredients in the cocktail. And officials say they are getting more drugs for their dollar by buying directly from the three U.S.-based manufacturers -- Abbot Labs, Merck and Hoffmann-La Roche.

"Brazil just sometimes does things that are more progressive and more forward-thinking than other countries that some might think more financially able," said Richard Parker, an anthropologist who has studied sexual behavior and AIDS policies in Brazil for 15 years.

Next to the United States, Brazil has both the highest population and highest number of AIDS cases in the hemisphere. In providing the protease inhibitors, which were speedily approved in the United States by the FDA early this year and extolled in July at the 11th International Conference on AIDS in Vancouver, British Columbia, it will be continuing a program begun in 1991, when it offered free AZT and other new drugs.

Initial estimates are that thousands of HIV-infected people will receive the new treatment.

Disease underreported

Brazil won't be the world's first country to offer the protease inhibitors at no charge, however, despite recent Health Ministry claims. Several European countries are already doing so. Yet there's no comparing Brazil's AIDS crisis with that of any European nation.

Due to underreporting, a common problem in developing countries, the Health Ministry record of 39,000 Brazilians who are HIV-positive is far off the mark, many believe. Two years ago, the World Health Organization estimated the true number at 550,000.

Underreporting is one of the main reasons Brazil chose to provide free AIDS drugs, according to Parker.

"You have to give patients and doctors some incentive to register the cases, so the government can track the epidemic," he said. "So the argument emerged that the more you can integrate people into society, giving not just drugs but psychological support, the less likely it is that they will go underground and infect other people.

"That's why, even though this idea has been criticized for not being economically sound, the benefits may in fact outweigh the costs," Parker added.

Compassion over cash

At the Pedro Ernesto state university hospital, Dirce Bonfim de Lima, who has been treating AIDS patients for the past 12 years, contended that the main reason Brazil is giving free drugs is compassion.

On a recent trip to Los Angeles, Bonfim said, she had been shocked to meet an AIDS patient who had just been told his insurance wouldn't pay for medication to fight an opportunistic disease that causes blindness. "My dear doctor, I am going to go blind," the man told her.

"Here in Brazil, this would never happen," Bonfim insisted. "I think it's a question of culture."

The cultural contrast isn't quite so grim. Most U.S. insurance policies so far are covering the cost of the new drugs, according to David Barr, an AIDS treatment expert at the Gay Men's Health Crisis in New York. And for uninsured patients in the United States, Medicaid or state-managed AIDS drugs programs often fill in the gaps.

Still, the new drugs' high cost remains a concern in the United States, Barr said, since many insurance firms have annual or long-term spending caps that are quickly reached by the expensive treatments. He said many of the state programs have run into arrears and a few have gone bankrupt. AIDS activists add that it is often hard to find doctors who will treat Medicaid patients.

Barr said he doubted droves of uninsured U.S. AIDS sufferers would rush to Brazil for the drugs, however, even though Brazilian doctors say they would be eligible.

"The people who aren't getting access to drugs in the States aren't about to be able to buy an airplane ticket to Brazil," Barr said.

Social priority

Nor is the overall quality of Brazilian public health care likely to inspire mass immigration. One prominent doctor in Brazil recently described the nation's health care system as "genocidal." Yet for a nation with a mind-boggling array of social problems, Brazil has made AIDS a priority.

"Our constitution says health is the right of everyone, but AIDS is seen as something transcendent, with special socioeconomic and emotional importance," said Pedro Chequer, head of the federal AIDS program. The arrival of the protease inhibitors in Brazil is not an unmixed blessing, doctors warn. As in many developing countries, they as well as other medications can be bought over the counter, and in the wake of the extraordinary worldwide hoopla about them, many people with AIDS are doing just that.

"This really scares us, because if you don't use them under the right conditions, they can be toxic," says Bonfim.

The drugs, which are capable of blocking an enzyme necessary for HIV to progress, must be taken under a complicated regimen, several times a day, some with high-fat food and some on an empty stomach. U.S. researchers still don't know which drugs combine best and what kinds of HIV-infected patients may benefit most from the treatment.

In Brazil, doctors plan to give first priority to patients at an advanced stage of the disease, or for whom other drugs are not working.

At the AIDS ward in the Pedro Ernesto hospital, Ana Maria Araujo da Silva, 46, is counting the days until Nov. 15, when the new drugs are due to be available. A former pastry chef and divorced mother of four, she said she discovered she had AIDS two months ago, when the disease was already well advanced, and has since been living at a Catholic hospice.

Last week she was admitted to the hospital, with her infection-fighting T-cells at an alarmingly low level of 70, huge purple lesions under her arms and CMV retinitis, an AIDS-related illness that can cause blindness. Her doctor, Bonfim, told her about the protease inhibitors and said she would be a good candidate.

"I could never afford the drugs myself," Araujo said, simply. "So the country has to help."

CAPTION: color photo: Dr. Dirce Bonfim de Lima talks with AIDS patient Ana Maria Araujo da Silva at Pedro Ernesto Federal Hospital in Rio de Janeiro (a)

KATHERINE ELLISON / Herald Staff ELIGIBLE FOR TREATMENT: Dr. Dirce Bonfim de Lima talks with AIDS patient Ana Maria Araujo da Silva at Pedro Ernesto Federal Hospital in Rio de Janeiro. Araujo is one of the patients with advanced AIDS who will be given priority in the treatments.

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