Good news from Africa, thank goodness:
Africans Outdo Americans in Following AIDS Therapy
By DONALD G. McNEIL Jr.
Contradicting long-held prejudices that 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 Americans are.
Some doctors, politicians and pharmaceutical executives have argued that it is unsafe to send millions of doses of antiretroviral drugs to Africa, for fear that incomplete pill-taking will speed the mutation of drug-resistant strains that could spread around the world.
The danger already exists: nearly 10 percent of all new H.I.V. 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 percent of their medicine. The average figure in the United States is 70 percent, and it is worse among subgroups 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 because of patent problems — no Western company makes all three drugs for an ideal cocktail.)
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 Organization 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 programs 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 H.I.V., the virus that causes AIDS. "But it will be a tragic mistake if it's not done right. You'll have `Eureka!' and `Thank you, America!' for two or three years — but then you'll 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.
Africa can still do better than the West, they say, by avoiding old mistakes. 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 who has studied compliance patterns here and abroad.
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 percent of his pills will, when tested with unannounced home pill counts or electronic pill-bottle caps, turn out to be taking 70 percent.
A study of 29 Ugandan patients found that, on average, they estimated that they were taking 93 percent of pills and proved to be taking 91 percent. |
