New Vision (Kampala) -September 8, 2003
Donald Mcneil Jr.

Contradicting long-held prejudices have clouded the campaign to bring AIDS drugs to millions of people in Africa. Evidence is emerging that AIDS patients there are better at following their pill regimens than the Americans.

Some doctors, politicians and pharmaceutical executives have argued that it is unsafe to send millions of doses of anti-retroviral drugs to Africa, for fear that incomplete pill-taking will speed up the mutation of drug-resistant strains that could spread around the world.

The danger already exists: nearly 10% of all new HIV infections in Europe are resistant to at least one drug.

For Africa, the issue is particularly touchy because it is tinged with racism.

In 2001 for example, there was an outcry when the director of the United States Agency for International Development said that AIDS drugs "wouldn't work" in Africa because many Africans don't use clocks and "don't know what Western time is."

Now surveys done in Botswana, Uganda, Senegal and South Africa have found that on average, AIDS patients take about 90% of their medicine. The average figure in the United States is 70%, and it is worse among sub-groups like the homeless and drug abusers.

Compliance has become easier because drugmakers from India and elsewhere are beginning to make triple-therapy cocktails that come in as few as two pills a day. These are not available in the United States yet.

After nearly a decade of watching Africans die because AIDS drugs cost $10,000 or more a year per patient, rich nations began pledging aid after generic competition in 2001 drove prices down to about $300 a year. Last week the World Trade Organisation agreed to alter its rules to give poor nations more access to life saving medicines.

But as with any epidemic moving through a poor and ill-educated populace, the threat of disaster clings like a shroud. Patients in badly supervised programmes have been caught selling pills or sharing with desperate relatives - acts of greed or mercy that could lead to doomsday strains of the virus.

Anti-retroviral therapy "is the No. 1 priority for the developing world," said Robert C. Gallo, director of the Institute for Human Virology and a pioneer in researching HIV, the virus that causes AIDS. "But it will be a tragic mistake if it is not done right. You will have 'Eureka!' and Thank you, America!' for two or three years - but then you will get multi-drug resistance, and whoops."

Drug-resistant strains are inevitable, doctors say, and turn up in every illness from malaria in Africa to children's ear infections in Manhattan.

Hard-to-cure variants evolve spontaneously in response to drugs. But they are more likely to grow and be passed on if patients skip doses, because triple therapy often suppresses even mutant strains. To avoid an epidemic of incurable AIDS, new drugs must be discovered faster than old ones become useless.

Today's drugs are more potent and no one will spend years on one drug, thereby breeding resistance, as many Westerners did on AZT before triple therapy emerged in 1996 moreover, doctors say, most African patients are zealous about their regimens. They are also more truthful when estimating their adherence, said Dr. David Bangsberg, a professor of medicine at the University of California, in San Francisco.

On average, he said, American patients tell their doctors that they are doing 20 percentage points better than they really are - that is, a patient who says he takes 90% of his pills will, when tested with unannounced home pill counts or electronic pill-bottle caps, turn out to be taking 70 per cent. A study of 29 Ugandan patients found that, on average, they estimated that they were taking 93% of pills and proved to be taking 91%.

Though poor, more than 80% of the Ugandans had jobs, though most earned less than $50 a month. Most were women in their 30's, and paying $27 a month for their twice-a-day, three-drugs-in-one pill called Triomune, made by Cipla Ltd. of Bombay.In many such cases, explained Dr. Merle A. Sande, a professor at the University of Utah medical school, who also works in Uganda, the whole extended family, possibly with several infected members, will chip in so that one member will be saved to care for the children.

"That's a whole different scenario from the U.S., where patients get free medicine, and if they change therapy, they will let a month's worth go to waste."

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