Concern in Africa over private doctors giving AIDS drugs

Here in this poor mountain kingdom, as across the African continent, the price of AIDS drugs has plummeted. A full regime of AIDS medicine, consisting of three separate drugs to be taken daily, once cost thousands of dollars a month. Today, after pressure from activists, the price is less than $50.

That's good news for people who have fought for years to bring AIDS treatment to the developing world. But anecdotal evidence indicates that many private doctors, some of whom lack specific training for AIDS care, are prescribing only part of the drug regimen, are failing to properly monitor patients for toxic side effects, or are failing to provide patients with accurate information about the importance of sticking with the program over a long period of time. Such therapeutic "anarchy," as critics call it, endangers both the patient's health and the long-term success of growing efforts to bring AIDS treatment to developing countries.

"Doctors feel that they should at least give something, and they don't realize that in the long term what they're doing isn't in the interest of the patient or the community," says Des Martin, president of South Africa's HIV Clinicians Society.

Public health experts have long worried about the rise of resistant strains of HIV, the virus that causes AIDS, if medications, called antiretrovirals (ARVs), were inappropriately administered in the developing world. Such fears were heightened by the announcement earlier this month about a new strain of HIV, found in a man in New York, that leads to the rapid onset of AIDS and is resistant to virtually all known ARVs. The UN estimates that 2.9 million people died because of AIDS in 2003, most of them in Africa.

In the past few years, billions of dollars have been pledged to bring ARVs to poor countries in Africa and other parts of the world. President Bush has proposed $15 billion emergency plan for AIDS, known as PEPFAR, and the president's proposed budget this year earmarks $3.2 billion for the program, much of which will go toward purchasing ARVs. Meanwhile, the UN has established the Global Fund to fight AIDS, tuberculosis, and malaria, approving grants for AIDS treatment totaling more than $1.5 billion.

The focus has been on developing dedicated treatment centers run by governments or nongovernmental organizations, with little attention being paid to the burgeoning distribution of the drugs by private doctors. In many poor countries like Lesotho, people tend to have little faith in the public health system and those who can afford it seek medical care from private hospitals, many run by churches.

"Both at the global and the national level there is still no clarity about how to work with the private, for-profit sector. We just don't have the tools to work with them," says Ruairi Brugha, a lecturer of public health at the London School of Hygiene and Tropical Medicine. Mr. Brugha wrote an article for the British Medical Journal in 2003 warning of the dangers of a uncontrolled private-sector distribution of ARVs in developing countries. "There are no easy answers, but I think its better to engage with the issue than to ignore it," he says.

The UN World Health Organization, which is leading the global drive for AIDS treatment with its ambitious plan to put 3 million people on antiretroviral treatment by the end of this year, estimates that 700,000 patients in the developing world, including 310,000 in Africa, are taking antiretroviral drugs, mostly through free clinics. But they admit that these statistics probably underreport the number obtaining the drugs through the private sector.

Little research has been done on the quality of AIDS care in the private sector in developing countries, but the few studies that have been done present a snapshot of a larger problem.

One study in Zimbabwe found that 17 percent of the patients were receiving mono, or single-pill, therapy and that most patients believed the drugs cured AIDS. In Uganda, researchers found that patients frequently had to switch drugs due to price variations and shortages.

Here in Lesotho, anecdotal evidence from doctors indicates the problem is widespread as well. Tonny Mwabury, a Tanzanian doctor who four months ago opened a small clinic in Teyateyaneng, about a half hour from Lesotho's capital, Maseru, was shocked at the number of patients he saw who were not taking the full three-pill drug regime. In his first three months of operation, he saw 24 patients who were taking antiretrovirals prescribed by private doctors in Lesotho and South Africa. Six of those were on mono or duel therapy. He even saw one patient who had been prescribed just 10 doses of a potent antiretroviral, Nevirapine, which is supposed to be taken for life in conjunction with other drugs.

Dr. Mwabury cites two reasons for the incorrect prescriptions. "One would be that the patients might not be able to afford the complete ARV therapy, and the doctors want money so they prescribe what the patient can afford. The second reason is that doctors are not knowledgeable about treatment with antiretrovirals," he says. "The biggest reason is probably lack of knowledge."

Some training has been done for private doctors in Lesotho and South Africa, but experts like Brugha would like to see governments and donor agencies do more to work with the private sector and control drug stocks. One strategy, he says, would be to ensure that the drug regimes available to the private sector were the same ones being offered in the public sector, to reduce the number of different drugs in circulation.

Other experts argue that wider availability of fixed-dose combinations, like the blister packs produced in South Africa which were recently approved by the US Food and Drug Administration for use in PEPFAR, are less easily abused.