July 14, 2003

Ed Susman

July 14, 2003 (Paris) -- Part of the failure of the world community to demand treatment for the 30 million people in Africa who are fighting infections with human immunodeficiency virus (HIV) might be blamed on myths that suggest treating desperately ill patients might somehow make the epidemic worse or is financially unsound, experts say.

However, Jean-Paul Moatti, PhD, professor of economics at the University of the Mediterranean, Marseilles, France, said those myths are not true — and the very opposite is likely to occur if nations devote time and money to attacking HIV/AIDS with money and medication.

In a keynote presentation here at the Second International AIDS Conference on HIV Pathogenesis and Treatment, Dr. Moatti attempted to rebut many of those arguments that may have hindered treatment in underdeveloped nations:

Myth #1: The use of antiretroviral drugs in unsophisticated, underdeveloped countries will result in nonadherence and lay the foundation for an invigorated epidemic of a resistant virus.

But, said Dr. Moatti, lack of adherence and risk of resistance doesn't stop the use of the antiretroviral medication in resource-rich countries. "We are applying a double standard to Africa," he said, despite studies in Côte d'Ivoire, Senegal, and Uganda "that demonstrate that viral resistance and nonadherence to treatment are no greater problems in cohorts of patients in Africa than in developed countries."

Myth #2: The treatment of patients in countries where annual per capita income is around $300 a year cannot be considered cost-effective.

Dr. Moatti said that use of generic drugs -- which he said should be permitted because health issues override intellectual property rights in these HIV-battered nations -- can bring the cost of treatment down to reasonable levels. In developed countries, if it costs $50,000 for treatment of an individual, that treatment is considered cost-effective. In African countries, if the treatment costs can be lowered to $500 or less it would be cost-effective.

He said programs in Brazil in which generic drug manufacturers produce enough drugs to offer universal treatment to infected patients have proven successful.

"Access to antiretroviral therapy is not just a moral imperative," Dr. Moatti said, "it is good economic sense." Treatment with the drugs will result in cost savings by keeping people out of hospitals and will prevent development of opportunistic infections, which require other drugs and hospitalization to treat, he said.

Myth #3: Prevention and therapy cannot be delivered simultaneously, because if people knew they would get treated, they would not be diligent in trying avoid the disease.

In fact, Moatti said his research shows that the availability of treatment enhances testing. If people know their HIV status, he said, they tend to increase their use of condoms to prevent infecting a partner. If drugs are not available, he explained, there is no reason for patients to get tested.

"There is now clear evidence in the HIV/AIDS field...suggest[ing] that prevention and treatment are indeed complementary," he said.

Myth #4: Differential pricing will destroy international drug innovation.

That argument, Dr. Moatti, said flies in the face of economic textbooks that support the concept that drug prices should reflect what countries can pay. Agreements have been signed to put that concept in practice. "The myth that it will impact innovation we know now is not true," he said.

Myth #5: Despite the fact that AIDS is ravaging countries, its overall impact on the economy of a country is not that great.

At its present pace, within four generations the economy of South Africa will be halved by AIDS, Dr. Moatti said, citing new figures developed by economists at the World Bank. "We now realize that the social loss for economic development related to AIDS has been significantly underestimated and that the potential economic benefits of antiretroviral therapy have been consequently underestimated," he said.

"We have an economic rationale now to deliver drugs to these people," said Michel Kazatchkine, MD, director of the National Agency for AIDS Research, the Paris-based French national AIDS research organization. "Three years ago people were still thinking we should go to prevention rather than treatment. Then people were saying the drugs are too expensive. Then people were saying drugs were not cost-effective. Then people were saying we don't know if the drugs will be effective in the context of the developing world.

"At this conference," Dr. Kazatchkine said, "we believe we are bringing evidence to fight against all of these arguments."

Not that the fault lies solely with wealthy nations, said Dr. Kazatchkine. "There are obstacles. There are still leaders in our scientific community who express concern [about] an epidemic of resistant virus. There is insufficient commitment among those in the developed world and in the governments of underdeveloped nations.

"There is insufficient coordination within the countries between the civil societies and the governments and the health sectors and financial sectors," Dr. Kazatchkine said in a press briefing. "There is insufficient manpower. But even with the available manpower we should be able to scale up treatment programs much better than we currently do."

Joep Lange, MD, from the Academic Medical Center in Amsterdam, the Netherlands, and president of the International AIDS Society, added, "All the money that has been pledged to fight AIDS in the underdeveloped world is not going to solve all the problems alone. There is also an implementation gap. But it is important that we are going to dispel the economic myths which are known to be a barrier to care."

Reviewed by Gary D. Vogin, MD

Ed Susman is a freelance writer for Medscape.

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