If only it were just the drugs…

pillsModern HIV medications are a testament to pharmaceutical ingenuity. In the space of 15 years we have progressed from having one weakly effective and highly toxic therapy to a whole medicine cabinet of  anti-retrovirals (ARVs), targeting the virus in different ways and in combination providing highly effective and tolerable ways of keeping it at bay.

They don’t represent a cure, but taken properly, with the right kind of ongoing check-up, nutrition and medical support if things go wrong, a HIV patient in the US or Europe can reasonably expect to live close to their normal life expectancy. That is remarkable progress from the almost universal death sentence that the diagnosis represented only 20 years ago (Eric’s story not withstanding).

So with such marvellous advances in medicine, why are countries like Zambia still struggling with significant levels of mortality associated with HIV?

Well the first thing to be clear about is that is no longer for want of the drugs. There was a dark time around the turn of the century when access to treatment was almost unknown across Africa. Pharmaceutical companies to their shame (and I speak as an employee and shareholder) were slow to respond to the needs of the continent and release patents or develop pricing strategies that were within reach of low-income countries. I am pleased to say that this era is behind us. I have visited the national stores and can personally testify that they are filled to roof with boxes of some of the most advanced HIV medications in the world. Clearly there were and still are issues beyond the supply of drugs to be dealt with.

The first thing to note is that is one thing to have a gleaming warehouse in Lusaka stacked with ARVs and quite another to ensure that each and every rural clinic at the end of 200km of dusty (or worse muddy) road is similarly well stocked. In addition, in a country where people often have to move to find work, even if your own clinic is well stocked, there is every chance that the one you move near to may not be (and you can be certain that they won’t have your medical records).

The second thing to remember that you can only begin your ARV therapy once you know your HIV status. With the notable exception of Cuba (which incidentally has managed to keep its HIV prevalence very low) most countries believe in voluntary counselling and testing (VCT). The V of this is important as it underlines the fact that unless an individual has the wherewithal and the motivation to get tested, they surely can’t begin to access treatment.

The third point is that even for those who are successfully diagnosed and put onto treatment, a fairly significant health infrastructure needs to be built around them to check on how they are tolerating the drugs, ensure that they do not need to switch medications and most importantly that they have access to medical services if things go wrong.

This is where a developing nation’s health infrastructure really begins to struggle. People don’t die from the virus itself, they die from the infections it leaves their body vulnerable to. Killer in chief amongst these immuno-compromised individuals is TB. A treatable disease that was on the verge of eradication a few decades ago has come roaring back and now kills more than 9,000 people per year in Zambia alone, 70% of whom are thought to also have HIV.

Of equal significance is the need for good nutrition to keep clients healthy during treatment. It is not an exaggeration to say that for some Zambians it is easier to access free drugs than it is to get fed. You know you have a problem when somebody who has just tested HIV negative asks clinic staff  to record them as positive so that they can access food and other support earmarked for HIV patients only.

And therein lies the rub; modern ARVs have essentially transformed HIV into a chronic disease. But chronic diseases require comprehensive health care systems to be effectively managed. There aren’t too many type II diabetics receiving great care in this part of the world either.

Whisper it quietly but some influential folks are beginning to question whether all this focus on HIV treatment and the support services they require are receiving too much effort and resources at the expense of other killers that are simpler and cheaper to treat – problems such as malaria and infant mortality.

Making ARVs widely and freely available has been an enormous success and unquestionably many lives have been saved in the process, but existing health systems and budgets are increasingly being overwhelmed in trying to manage the growing population of clients on treatment. There have been some glimmers of hope: studies have found that African patients have very high rates of compliance to their medications and that the frequency of monitoring used in developed health systems may not be required.

However the unpalatable truth remains, that unless and until rates of transmission begin to drop or a vaccine is developed (slightly encouraging news this week but still at least a decade off) countries with weak health infrastructures like Zambia and donors such as the US government will increasingly find themselves between the devil and the deep blue sea.

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Comments
3 Responses to “If only it were just the drugs…”
  1. Sridhar Reddy says:

    Very insightful, B. I saw this in the US as well, where a doctor’s diagnosis was to simply carpet-bomb patients with antibiotics, leaving the patients depleted of gastrointestinal flora and basically open to nosocomical infection.

    I’m curious though, what is Africa’s stance on homeopathy / naturopathy and preventative medicine? Granted I assume there in no homeopathic treatment for HIV (although who knows there could be), but perhaps homeopathy can be used as an immuno-booster or as a treatment for the myriad of secondary problems that ARV users face.

    Keep up the great work. Your blog is really one of the highlights of this year for me.

    • berkeleysblog says:

      Hey Sridhar,

      As you can imagine in a world that had no effective treatment for a very long time, there is a whole world of ‘alternative’ treatments offered here for HIV. Most of them centre around traditional African medicine, some potentially of mild benefit, a lot of it positively harmful.

      Shockingly there is a whole movement based upon AIDS denial and in particular denial of the value of ARVs, pushed primarily by the purveyors of multi-vitamins. This would be a sick joke if it hadn’t managed to permeate the very top of South African politics in the early 2000s, delaying treatment roll out and costing many thousands of lives.

      See this article in Bad Science to see how sinister things can get http://www.badscience.net/2009/04/matthias-rath-steal-this-chapter/#more-1088

      Thanks for your continued interest in the blog and the kind words
      Berkeley

  2. Sridhar Reddy says:

    That BadScience article is a real downer, but I’d be lying if I said I wasn’t shocked by bottom-line driven intentions. Too bad human nature doesn’t make business stop at a profit, it has to make a killing. Literally and figuratively.

    The politics of pharma is eye-opening and sobering, and I can only think that major change agent is educating the consumer. Where there is choice and voice, there is power.

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