Newsday - July 12, 2000
Laurie Garrett. Staff Correspondent

Although the results appear mixed and point up obstacles to providing such medical care in poor countries, most clinicians and scientists in attendance appeared convinced that Africans will be able to follow the drug regimens-if they become available via lowered prices. The potential for adherence to such a demanding regimen has been challenged by skeptics.

"With regard to the enthusiasm and feasibility of treating in developing countries: Not only would that be important," Dr. Anthony Fauci, director of the U.S. National Institute of Allergy and Infectious Diseases, said in a news conference, "but it could also have an enormous impact on the kinetics of the epidemic."

A recently published study done in Uganda's Rakai District found that the probability that one individual would pass the virus on to another was strongly linked to one factor: the number of viruses in the bloodstream of the infected person. So anything that could lower the viral load would theoretically lower the probability of passing on the virus to a sexual partner, Fauci said.

Fauci, a veteran of international AIDS meetings since 1985, spoke optimistically about applying the fruits of U.S. and European drug research to Africa's pandemic-even as he detailed the complications seen with use of highly active anti-retroviral therapy, or HAART, in the United States. And he called for a new strategy for use of drug combinations, one that would interrupt treatment to give the immune system a chance to battle the virus.

Further complicating use of HAART in the United States is a consensus among western researchers that no matter how effectively the regimen appears to reduce viral loads, HIV nevertheless continues multiplying in hidden reserves of the body. Worse, each of the 10,000 genetic sites on the virus typically mutates every day in an AIDS patient, said Dr. David Ho, director of the Aaron Diamond AIDS Research Center in Manhattan. Even in "successful" HAART patients, Ho noted, HIV escapes the drugs through means that remain mysterious.

Scott Holmberg of the U.S. Centers for Disease Control and Prevention tracked 232 American patients on HAART for more than 15 months and found that in the most successful patients, a mean of 5.3 months passed before resistant viruses emerged, necessitating alteration of the drug combination. With each subsequent drug combination, the time span shortened, he said.

In Brazil, where the government provides HIV patients with free HAART drugs, physicians have seen a marked decline in mortality rates, said Dr. Mauro Schechter of the Federal University in Rio de Janeiro. But their patients average only four months on HAART before the first drug combination fails. Further, "several published reports have documented that impressive declines in mortality rates actually preceded the availability of HAART by several years," he said.

AIDS mortality rates in Brazil fell by 60 percent before HAART was introduced, Schechter said, because of widespread use of drugs to prevent tuberculosis in HIV patients. Haiti saw an 84 percent decline thanks to TB prophylaxis.

"Clearly, other factors besides HAART have influenced these declines in mortality rates," Schechter concluded.

Despite these caveats, HIV patients in poor countries, their doctors and AIDS activists are here demanding HAART drugs.

About two dozen demonstrators from ACT UP staged a brief but loud demonstration in the convention center yesterday, blowing whistles and chanting "medication for every nation" to protest what they said was the World Health Organization's failure to make AIDS drugs available to poor people.

The demonstration could be heard in conference rooms and drowned out one in which dissident scientist Dr. Charles Geshekter was promoting his view that the AIDS threat is overblown and that drugs being used to treat it, such as AZT, are more dangerous than the disease itself. Geshekter sits on the controversial panel convened by South African President Thabo Mbeki to study, among other things, the dissidents' claims that HIV does not cause AIDS and that millions of people dying ostensibly from the disease are really falling victim to ailments such as malaria and tuberculosis.

At the same time, South African researchers were presenting results of a study that they said proved the safety and efficacy of nevirapine given to HIV-positive pregnant women to prevent infection of their babies. Mbeki has used the dissidents' claims of toxicity of AIDS drugs as one reason for his refusal to make nevirapine available to pregnant women and to victims of rape.

Dr. James McIntyre of the Perinatal HIV Research Unit at Chris Hani Baragwanath Hospital in Soweto said that results from 1,300 women showed nevirapine was "safe and well tolerated. Many governments have been loath to act based on results of just one [positive Ugandan] study, which is fine. This study shows it works." In South Africa, he said, four women died, but none from nevirapine- related ailments.

The only potential drug-related adverse events were rashes, said McIntyre, adding that he was "hopeful" the study might persuade the South African government to change its stance.

Another South African study found the drugs ddI and AZT safe for use by pregnant and breastfeeding women. And a CDC study done in the West African nations of Burkina Fasso and Cote d'Ivoire found that even when HIV-positive moms breastfed their newborns, AZT reduced the likelihood their children would become infected through contaminated milk by 8 to 10 percent.

A joint CDC and Uganda study of 905 adult HIV patients found that most could "tolerate the HAART drugs and take their complicated medicines properly," Dr. Raymond Mwebaze of Mulago Hospital in Kampala said. After 12 months of treatment, 54 percent were still taking their HAART, 17 percent were dead and 21 percent had stopped the drugs or simply disappeared. However, only 48 percent were still keeping their doctor's appointments.

The main reason these patients dropped out of treatment was money: The drugs, though discounted, were still expensive. And when patients ran out of money, stopped taking their drugs or missed medical appointments, resistant forms of the virus emerged, the CDC's Dr. Eve Lackritz noted. After a year, 78 percent of the Ugandans who were still showing up for clinical appointments carried viruses that were resistant to the drug 3TC, and 20 percent had AZT resistance.

In Cote d'Ivoire, a United Nations AIDS program-sponsored study made HAART available to patients in Abijan. Again, patients had to pay part of the price for their drugs, and 658 were turned away because they couldn't afford the cost.

Among the 1,064 who took HAART, half lowered their viral loads to undetectable levels within 10 months. But drug resistance was a problem, said Dr. Christianne Adje of the Ministry of Health. Before the study began, patients were screened for drug resistance because 422 of them had already been taking HAART drugs obtained on the black market. Drug-resistant viruses were found in half.

"The high prevalence of resistance may lead to treatment failure when antiretroviral therapy becomes available in Africa," Adje concluded.

African correspondent Tina Susman contributed to this story.

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