The use of antiretroviral drugs had led to a dramatic and incredible decline in deaths and hospitalisation of Aids patients in the US, and South Africa with its high Aids figures urgently needed to find ways of making the treatment widely available, said Dr Gerald Friedland, director of the Aids programme at Yale-New Haven Hospital in the US.

Speaking at the Treatment Action Campaign’s expert consultation in Johannesburg last week, Friedland warned, however, that the health care system in South Africa was completely unprepared for a programme of antiretroviral therapy (ART).

The US success story was due largely to the comprehensive systems of care which were set up shortly before the therapy was introduced, he said. It was necessary to have facilities in place for providing the drugs, as well as a therapeutic environment for attending to the patients’social, psychological and physical wellbeing. Staff also needed the clinical expertise in diagnosing symptoms and prescribing medicines.

“Without this infrastructure it would not have been possible to implement ART,” he said. “Yet very little of the clinical structure is in place in South Africa and there is very little attention to establishing outpatient settings where drugs could be administered and the patients followed up.

“My observation is that South Africa desperately needs to develop these systems of care – without this any benefits of ART will be minimal.”

Describing the marked effects ART had had in the US, Friedland said HIV infection had been the leading cause of death in the 22 to 44 year age group in 1994, but following the introduction of ART in 1996 there was a sudden and dramatic drop in deaths due to HIV infection and by 1998 HIV was low on the list of killers.

The rate of death due to HIV infection was four times higher before ART was introduced. As the therapy had only been in use for a relatively short time, it was too early to say for how many years a patient could live after they were diagnosed with HIV. The introduction of highly active antiretroviral therapy (HAART) resulted not only in a dramatic decrease in all opportunistic diseases but in fewer patients being admitted into hospital and instead being attended to as outpatients – a far cheaper alternative.

This change in the flow of patients led to a change in the balance of the overall cost for treating HIV infection. As the pharmacy bill increased with the introduction of ART, so the inpatient bill decreased and in the end the drugs paid for themselves. Other countries had experienced the same cost benefit of HAART, and figures from the Brazil ministry of health showed that through the use of HAART it had avoided 146 000 hospitalisations during the period 1997 to 1999, which amounted to a saving of $472 million.

It was estimated that of the 36 million people living with HIV/Aids in the world at the end of 2000, 25 million were in subSaharan Africa, he said, and unless there was an intervention Aids would take out huge numbers of the South African population within the next few years. Its effect on the health care system would be far-reaching.

Recent projections showed that the number of student nurses infected with HIV could rise from its 2000 figure of 23% to 40% in 2010. Yet South Africa was in the enviable position of being able to benefit from the lessons of the past “mistakes” of other countries, said Friedland. Other countries had had to learn through trial and error how to tailor the drug regimens to get the potency right.

Often the regimens had been too complex and the drugs too toxic and there had not been enough attention to the problems of adherence to the regimen and to drug resistance. These were all problems that other countries had had to iron out and through heeding these lessons, South Africa could avoid the pitfalls.

One of the central problems in drug therapy was adherence to the treatment regime, and here solutions still needed to be found. Unlike other medications, where 80% compliance was usually acceptable, ART was not effective unless there was 95% compliance. This element was gaining increasing recognition and ways were being developed to monitor adherence – even to the extent of counting the number of times the bottle is opened through the device of a microchip embedded in the lid of the bottle of pills.
Health-e News Service