TCS Daily

The Worst Pandemic Looks to Get Worse

By Roger Bate - February 20, 2004 12:00 AM

Fake AIDS drugs, unlicensed copies, real bioequivalent generics and even stolen brand name drugs are being sold on street corners in many African cities. The immediate result is that wretched Africans are spending their life-savings in the hope of prolonging their lives a few months, but are actually buying something useless, or at best something that is unlikely to keep them alive for long. The inevitable result is something far more worrying for society -- the build up of fatal drug-resistant HIV.

We are told that the AIDS pandemic is the worst we have ever seen, and that we must treat at least three million of the 26 million Africans with the disease as soon as possible. Humanitarian urges like this are understandable but Africa simply is not currently capable of administering complex medicines like anti-retroviral therapy to even 250,000 Africans. But, like those trapped in the Soviet Union during the cold war, and described so evocatively in Martin Cruz Smith's novel Gorky Park, believing in the lie that escape was possible was preferable to just contemplating day-to-day life. And so it is with the millions of Africans with AIDS, they want to believe that they can get better -- so they buy treatment, no matter how many lies, and ineffectual drugs, they have to swallow.

Each life lost is a human tragedy, and perhaps as many as one adult every 20 seconds dies from AIDS in Africa. But the long run impact on drug development is the most worrying part of this tragic process.

In Kenya, the main street trading takes place on Tsavo Road in the capital Nairobi. Here one can buy aspirin, cancer drugs, any number of antibiotics and anti-retrovirals (ARVs) with or without a doctor's prescription. This is a market of cutting deals, there are no receipts, no credit card transactions and, above all else, no questions. According to one newspaper report, the average price of drugs sold on Tsavo Road is about 40% cheaper than at the established pharmacies. And because deals are done secretly, many patients prefer to buy their drugs there rather than dealing with the real, and often imagined, stigma attached to being HIV-positive in Africa and receiving treatment at an "AIDS clinic."

The sources of the drugs remain a secret and the traders are not letting on. It is likely that unscrupulous clinic employees are stealing supplies and selling them at cut prices to the street vendors. At least the stolen supplies they sell are likely to be branded drugs or bio-equivalent generic drugs. But from one survey in Kenya, the majority of drugs on sale were outright fakes which were ineffectual or poorly manufactured copies with active ingredients in the wrong proportions, which actually make them dangerous.

Fake drugs are appearing everywhere today. According to a Doctors Without Borders report, untested Indian generic copies of ARVs have now appeared in the Democratic Republic of the Congo. The DRC has almost no HIV program, it's impossible to know how many people have HIV in the country, yet counterfeit or poorly dosed copies are being taken by people in unsystematic treatment. It's more like the way westerners would take aspirin for a headache, haphazard and individually determined.

Even high quality drugs supplied through clinics might be taken in irregular doses or even shared out or sold, because drugs are sold "in installments." In effect, a patient can buy two weeks' supply of an antiretroviral, even though the danger of discontinued use means sickness and possible resistance build up. Furthermore, because supplies are sporadic, the patient returning for his next installment might find it unavailable. In such a case a patient will have to take an alternative therapy, irrespective of whether switching is appropriate.

An official identified in a Wall Street Journal story last week said the Nigerian antiretroviral program was "in crisis." The same story reported that in Geneva, Andy Searle, an advisor to the Joint UN program on HIV/AIDS, said interruptions in the drug regime could lead to the virus developing resistance to the drugs. "Even if someone were to miss one or two doses taken every 12 hours, they risk developing resistance...It's a concern when the drug supply is broken."

In Nigeria, where Indian generic drugs have passed their sell-by date, doctors are still prescribing them because they have nothing else to give. No new supplies have been ordered and the street vendors are the only people with drugs to supply; one local health official said most of the drugs are fakes.

There are also numerous HIV test kits available. Since perhaps 90% of Africans estimated by UNAIDS to have HIV are unaware of their condition, testing is a vital ingredient in the mix. But these kits may give people false hope by being out of date and hence giving false negative test results. Even where the kits do work, one cannot be certain they are accurate, since only the Kenya Medical Research Institute has the technology available to verify the results.

So far, less than 100,000 Africans are taking ARVs in decently monitored programs (and that includes the alleged 14,000 Nigerians who now have no drugs. Many news reports claim that only a few thousand and not 14,000 were actually receiving treatment). In any event African infrastructure is slowly being developed so that perhaps 250,000 will be treated by end of 2005. While this is great for the treated individuals, unless resistance management is radically improved, we may have such a drug resistance problem by then that it might be pointless getting treatment.

At a time when many drug companies are wondering whether to continue researching into AIDS drugs, because of the lack of expected profitability, the news that resistance is likely to build up because of fakes, and poor regimen adherence, is unlikely to convince them to stay in the AIDS research field. Without their research AIDS will never be brought under control.

Dr Roger Bate is a director of health advocacy group Africa Fighting Malaria. He last wrote for TCS about the World Health Organization.


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