PANOS; Tuesday, June 16, 1998
James Deane

The conference takes place against a backdrop of a rapidly growing 'treatment gap' between those affected by HIV in the rich North, and the vast majority -- more than 90 percent of all patients -- who live in the developing world. Advances over the last two years in so-called "antiretroviral therapies" (ARVs) -- the best known of which is AZT -- has meant that AIDS no longer needs to be a killer disease. In much of Europe and North America where ARVs are commonly prescribed as part o f a multi-drug therapy, death rates from AIDS have more than halved. While such therapies cannot cure AIDS, they have turned it into a 'manageable' illness.

The treatment gap is prompting demands that people in developing countries should not be excluded from the benefits of the new therapies. The problem is that these drugs are both extremely expensive and can kill if taken in the wrong doses. A year's treat ment can cost more than 10,000 dollars. As a result, ARVs have generally only been available in rich countries.

The dilemmas faced by AIDS workers are certain to be a key -- and highly emotive -- issue at the conference, the theme of which is "Bridging the Gap." "The gap between treatments for the haves and treatment for the have-nots is enormous and that is the bridge that has to be built if we're going to seriously address the issue," says Warren H. Lindner, a senior adviser to the Conference. "If we don't address the gap then millions of people are going to die and all we can do is help them die in a peaceful way -- that is wrong."

However, many AIDS workers and scientists are concerned that providing the most recent ARV therapies to people in developing countries could do more harm than good. They say the treatments are too expensive, require highly sophisticated health systems toaminister and could, if wrongly administered, lead to the development of even more virulent and drug-resistant strains of HIV. They argue that money is best spent on less expensive medicines which, while not slowing the onset of HIV, can alleviate pain a nd treat the "opportunistic infections" associated with AIDS.

"We must not raise false hopes," says Rachel Baggaley of the World Health Organisation (WHO), speaking at a conference organised by the UK NGO AIDS Consortium in London recently. "The worst thing we can do is to give intermittent or less than optimal therapy."

Dr Anton Pozniak of King's College Hospital in London agrees, arguing that if cheap treatments for tuberculosis, a disease which kills one person every 15 seconds, have not reached the people who need them, then much more expensive AIDS therapies won't either. Pozniak told the conference: "We have had a cure for TB for 30 years and it costs just 26 dollars for a full treatment. Yet more people are dying of TB now than ever before. There are eight million cases of TB every year, yet only five million of these rec eive some form of treatment for the disease."

Cost is not the only problem, according to Pozniak. Such drugs require expensive and sophisticated medical equipment to ensure that patients re getting the right dose, with patients typically having to take a complex cocktail of between 10 and 24 pills a day. If these drugs are not taken correctly, they can accelerate rather than slow the disease.

In contrast, pills which can cure TB need only be taken once a day. Yet studies have found that even in the United States as many as half the patients fail to take the pills properly. "Drug resistance to antiretroviral therapy can develop in just 21 days," warns Pozniak.

Kassec Mussa of the Medical Missionaries of Mary who works in Ethiopia points out that in her country, where the health ministry estimates there are more than 400,000 cases of AIDS, there is just one doctor for 31,000 people. Basic drugs such as paracetam ol are often unavailable. Health workers believe that introducing ARVs into such poor countries would only divert resourcesaway from less effective but more affordable drugs.

Despite such views, pressure is growing to broaden access to these drugs. "There are now more than 30 million people with HIV, most of them in the developing world," says Dr Joseph Saba of UNAIDS, the United Nations agency which coordinates the global response to AIDS. "We cannot ignore the fact that, unless we fin ways of ca ring for people, those people will fall into sickness, poverty and exclusion, the very conditions that make it more likely that they will pass the virus on to others."

Saba heads a new Drugs Access Initiative, which aims to provide wider access to drugs which can treat sexually transmitted diseases and the 'opportunistic infections' -- such as diarrhoea -- associated with AIDS. It is also trying to provide "more targeted access" to ARV drugs in developing countries. The French government has launched a similar initiative which is designed to provide a range of drugs, including ARVs in developing countries. "This is designed to mobilise additional resources and will not draw on existing AIDS funding in developing countries," Eric Chevallier, an adviser to the French Ministry of Health, says.

But both initiatives will start on a very small scale. The UNAIDS initiative expects to provide 2,000-3,000 people with ARVs in just four pilot countries in its first year. The French project will reach a similar numbers of people -- mostly pregnant women . A multinational drug company has agreed to provide its drug, AZT, at subsidised prices to initiatives working to prevent mother-to- child transmission of HIV.

The modest scale of such initiatives is incresing the frustration of those who say little is being done for people with HIV/AIDS in developing countries. "Out of six million people with HIV or AIDS in Asia, around 2,500 are receiving ARV therapies," Joe Thomas of the Chinese University of Hong Kong, who surveyed seven Asian countries, points out.

"We don't have access to even some of the basic medicines," David Chipanta of the Network of African People Living with HIV/AIDS says. "Governments and donors must provide care, including drugs for opportunistic infections and ARV treatments."

Many activist organisations argue that much greater resources could be mobilised for AIDS than for other diseases, such as TB, because AIDS is much more visible and 'better understood' in industrialised countries.

"We have this unique opportunity now to draw attention to AIDS in developing countries," says Marie de Cenival of ACT-UP, Paris. "AIDS research and care in North America and Europe has only received adequate resources because we have demanded them. We can do the same with AIDS in developing countries."

Efforts to provide ARVs in developing countries are likely to focus in the short term on pregnant women. Recent trials in Thailand have shown that relatively short courses of AZT can radically reduce the chances of an HIV-positive pregnant woman passing o n the virus to her baby.

Editor: Dipankar De Sarkar. Publishers are asked to send clippings of published features to Panos Features, 9 White Lion Street, London NI 9PD. Panos Features are also available on the Panos website: . If you would like to receive features by email contact Mark Covey on: (END/PANOS/JD/DDS/98)

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