iClinic - July 13, 2000
Marjolein Harvey

Access issues have dominated this conference, but a lack of political will at national level and funding at international level is leaving activists, representatives from resource-poor countries and others, with an increasing sense of hopelessness and anger.

Several African governments, such as Cote d'Ivoire, Botswana and Uganda, have shown their determination to implement mother-to-child transmission (MTCT) programmes and begin expanding antiretroviral pilot projects, but others, including our government, have so far remained silent.

Announcements of international initiatives from the US and EU have been weak on treatment components relative to the enormity of the need.

Cost, lack of infrastructure and toxicity have been put forward as the main barriers to treatment in resource-poor countries, by pharmaceuticals and government officials, but activists and international organisations like medical humanitarian organisation Medicines sans Frontieres refute these as lame excuses.

"What is missing is an attempt to build on the successful strategies of Brazil and Thailand to dramatically reduce the prices of AIDS drugs," said Daniel Berman from MSF's Access to Essential Medicines Campaign.

"The few developing countries that have achieved significant access for people with AIDS have done so by aggressively pursuing generic strategies."

In Brazil, 80 000 people were treated through use of affordable generic drugs that brought triple-drug therapy down to a cost of about R7 000 per year.

With Brazil having saved R3 billion on bypassing hospitalisation and treatment of opportunistic diseases and SA's ability to locally produce many of the essential drugs it seems inconceivable that government is not seen to want to find out more, and instead has taken on a defensive stance and seems to think this conference a waste of time.

"We are carrying out programmes to reduce HIV transmission from mothers to newborns and we know it is working, but we are also seeing a dramatic impact on people's willingness to get tested and their attitude towards HIV due to the existence of these programmes," said Eric Goemaere, MD, Head of Mission, MSF South Africa.

Government officials and pharmaceutical representatives tend to stress that treatment is not an option in attempts to control the pandemic in resource-poor countries, but MSF says it has never claimed that one can control an epidemic by treatment alone.

It argues that prevention without any possibility of care is not working. "Why should anyone get tested if they have no chance of accessing treatment? Treatment programmes will reinvigorate prevention efforts," says MSF.

The conference has seen several announcements of new initiatives by drug companies and international agencies. These initiatives need to be put into perspective.

Experience with Pfizer's fluconazole donation shows that these programmes are likely to come with unacceptable conditions for national health ministries and will not be sustainable over the long term.

One third of the world's population lacks access to essential medicines for a variety of diseases, including those associated with HIV/AIDS. The MSFsays that in the poorest parts of Africa and Asia that number is more than 50% and that the spread of the epidemic has been exacerbated by the lack of access to medicines.

95% of the 34 million people with HIV/AIDS remain without access to treatment. One of the reasons is that the global trade system sets rules for how products are sold within and between countries.

MSF says this system treats medicines like other non-essential products and finds this unacceptable. Through dramatically expanded generic production and bulk purchasing, the price of antiretroviral treatment could be reduced to as little as R1 400 a year.

MSF calls on wealthy nations to make firm commitments for Increased funding for these treatments and for the strengthening of national AIDS programmes that UNAIDS estimates need an additional R21 billion annually. International AIDS activists criticise Merck's five-year R300 million medicine and consultation donation to Botswana and other similar donations by pharmaceuticals because its hidden "strings attached" discourage resource-poor countries from pursuing self-sufficient, sustainable policies that would provide access to medicine without reliance on corporate generosity.

They also say that donation programmes distract from the refusal of industry to reduce prices to a level relevant to the financial capacities of poor countries. The widely reported UNAIDS initiative with the "big five" drug companies created hope worldwide, which was dashed when it became apparent that it was more PR than tangible results for the millions without treatment for preventable, curable diseases.

Merck was unable to say at a press conference when treatments would be available for people in Botswana and does not appear to have a plan or programme on paper.

Announcements such as Merck's "demonstrate that the pharmaceutical companies are getting panicky in the face of rising demands for generic products", according to international AIDS activist NGO Act Up.

MSF and others do not want to lose the political momentum built up at the beginning of this conference by the global march for access to treatment and wait for Barcelona, the IV International AIDS conference in 2002.

Arguments that resource-poor nations do not have the health infrastructure to bring drugs to the people are refuted by MSF's Christopher Ouma, MD who works in a Nairobi, Kenya public hospital.

"Governments and pharmaceuticals saying that African countries do not have the infrastructure to handle the treatments are condemning people to death before they even have a say. Yes, our infrastructure is bad but we need at least an effort to reduce MTCT and save a significant number of the 40-50 000 babies who are born with HIV each year in Kenya."

MSF doctors said in a press conference on Wednesday that some resource-poor countries have a vibrant drug manufacturing industry. In Kenya, for example, out of 15 antiretrovirals, only nine have patents.

MSF wants to use this gap to register generic products."We can do something now. We have to spur government on to action," says Ouma. David Wilson, who works for MSF in Thailand, says that fluconazole had no patent in Thailand, but until two years ago trade barriers prevented its generic production.

"We brought the price down very quickly from $14 to $0.60 through generic competition. Before this, our hospital was full of cryptococcal meningitis patients. Now the situation is so much easier to manage in our resource-poor hospital because people can afford the treatment," says Wilson.

In Thailand there was a lot of political will and national pride and the department of health provides MTCT in at least three provinces, with the healthcare system coping well, reports Wilson.

MSF and others' messages at this conference is that resource-poor countries should not be forced to accept expensive drugs through a controlled global trade system, but be allowed to shop around the world or locally produce essential and life-saving medicines.

This would break the sense of hopelessness that is emerging at this conference, not the empty promises of profit-driven PR of an industry that refuses to engage in dialogue.

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