AIDS IN AFRICA: The Lazarus Effect - Pharmaceutical Executive


AIDS IN AFRICA: The Lazarus Effect

Pharmaceutical Executive

She was referred to TASO, which functions as the hospital's AIDS clinic, and, although close to death, she was put on ARVs sponsored by PEPFAR. She's on the first-line treatment regimen for AIDS patients with TB: Zerit, Epivir, and Sustiva. After five months of treatment, she says the drugs brought her back to life.

She says it was hard to follow the regimen at first, but TASO and Godfrey counseled her children and sister on how she should take the medication, which kept her compliant when she was too sick to know what day or night it was. Now, she says, it is second nature to her.

After the ARVs, she discusses the short-course therapy she's on for TB and the Septrin (cotrimoxazole) for prevention of opportunistic infections. She picks up the last bottle and pulls out the last pill, a pink, oval Diflucan (fluconazole), trade dressed for donations to differentiate it from the ones Pfizer sells in town. Kakande promises to get her more tomorrow, but says because of the restrictions on the Diflucan program, he can't leave it with Godfrey. However, he will leave it with her sister, who works close to TASO Masaka, to save him the trip back to the hut.

There are immense benefits to home care like this—not least, the way that it accommodates for patients who have children in a way that a hospital or clinic in the city never could. (The average Ugandan woman has between four and five children, a fact that adds a whole new layer of concerns to AIDS care.) But again, home care does not scale up easily or inexpensively, and there are both concerns and opportunities—especially in the area of prevention of mother to child treatment—for the role it will play in scaling up AIDS treatment.

As he leaves, Kakande hands her 10 individually wrapped oral hydration swabs, before marking the additional notes on the form. Her eyes light up—so many! Kakande responds, before getting back on his boda-boda, "God is good."

For Better or Worse AIDS care in Uganda in the next few years is likely to be defined by PEPFAR. The choices the Bush administration has made offer some real advantages to patients, but they also have serious drawbacks. First the good news:

Proven drugs. The US government stipulates that only FDA approved drugs can be used in PEPFAR-funded programs. Therefore, the use of ARVs in those projects are based on tried and true clinical practice guidelines with proven outcomes—which is especially important for children.

"Up until PEPFAR-funded activities started, Mulago was using a lot of generics," says Mark Kline, director of the Baylor International Pediatric AIDS Initiative, which helps operate the pediatric AIDS clinic at Mulago, among several other pediatric AIDS clinics. "Many of the fixed dose combinations (FDCs) were only available in adult formulations, so clinicians were halving and quartering pills without any documentation that this made sense pharmacologically. Even if the brand-name drugs are more expensive, we should still use the drugs where we have all of the data and we know that if they are used correctly, they will achieve the desired results."

Certainly, the de-listing of several generic ARVs from the World Health Organization's prequalified list in recent months, including medicines from Cipla, Ranbaxy, and Hetero Drugs, cause some to believe that generics have the potential to sabotage growing treatment efforts. After all, the World Bank had already procured and distributed the de-listed generics for 2,700 patients through the Multi-country AIDS Project (MAP).

"It is extremely disappointing," says Peter Nsubuga, MD, MAP project manager. "But you end up having to continue the treatment—we cannot take back the drugs that we have already procured. So we shall proceed, I guess. We shall proceed and finish the drugs and then make new plans."


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