|Uganda Ministry of Health - UNAIDS HIV/AIDS Drug Access Initiative - Preliminary Report (UNAIDS, 2000, 14 p.)|
The early successes of the UNAIDS Drug Access Initiative pilot programs have come through an important human and financial investment and national commitment. Training and capacity-building have proved to be important components in a program aimed at expanding access to antiretroviral therapy in Uganda. Access to antiretroviral therapy, however, remains extremely limited, primarily due to the high cost and technical sophistication required for medications and monitoring. To date, nearly 1,000 AIDS patients have started ARV therapy out of an estimated 1.5 million persons living with HIV/AIDS in Uganda. Efforts to expand access to antiretroviral therapies must weigh the benefits and costs to the health sector. Even if patients meet the costs of their medical care, costs of training, development and implementation of treatment guidelines, and expanded access to laboratory diagnostics require substantial investment. Although newly-reduced drug costs have been announced, scaling up of antiretroviral treatment programs will be limited by the rudimentary laboratory infrastructure in the periphery and the median $300 annual per capita income. In this context, the importance of HIV prevention must remain the cornerstone of programs to prevent AIDS-related morbidity and mortality in Uganda.
That being said, the benefits to patients accessing this initiative are already evident. Although adherence has not yet been evaluated, changes in viral load and CD4 suggest that patients are taking their medications and responding to treatment. In this regard, this pilot program has demonstrated that AIDS patients can be managed successfully with antiretroviral therapy in a developing country setting. Promoting access to therapy earlier in the course of the patients disease would be expected to further improve patient outcome in this initiative.
To date, approximately half of patients started on antiretrovirals were started on 2NRTIs. The drug costs to the patient are lower, and clearly patients on 2NRTI fared better than what would be expected without therapy. Dual NRTI therapy still bears a substantial cost to the patient in this setting and is associated with a less durable benefit compared to HAART; average CD4 counts and viral load of patients on 2NRTI approached baseline values by one year after initiation of therapy. Extending survival for a matter of months might drain family resources needed for living expenses and education of surviving family members. More information is needed to assess the social and economic impact of this program on patients and their families. Lowering costs of protease inhibitors and nonnucleoside RTIs in this environment would have an important impact on the number of patients who can access HAART and the outcome of patients who are started on antiretroviral therapy.
Resistance to 3TC is conferred by a single drug mutation; emergence of 3TC resistance would be expected to occur, particularly when 3TC is not used as part of a maximally suppressive regimen. With recently reported reductions in the cost of AZT/3TC combination therapy, it is possible that more patients might access this regimen without the ability to afford HAART. It will be important to continue to evaluate clinical practices, patient response, and emergence of resistance as this initiative continues and as new programs develop.
This initiative to date has focused primarily on access to antiretroviral drugs. The initiative has also served to increase awareness of AIDS care and to the fact that patient management, record keeping, laboratory monitoring, and capacity building for the early diagnosis and management of opportunistic infections are all critical to the appropriate care and support of AIDS patients. The medical information system has proved to be an important tool for program evaluation and identification of ways to improve patient care within Initiative. To date, CD4 and viral load monitoring have been supported by outside agencies; the impact of moving this financial burden to the patient is unknown. More work is needed to define if alternative, less expensive monitoring strategies can be developed and implemented in resource-restricted countries. Promotion of AIDS care, and not just AIDS drugs, has been an important component to the success and evolution of this pilot program.
Programs are now underway to expand access to prophylaxis, diagnosis, and treatment of opportunistic illnesses in Uganda. This will benefit both patients who are on antiretroviral therapy and those who are unable to afford or otherwise access antiretrovirals. In addition to clinical training activities, these initiatives will need to address issues of drug procurement and distribution, stock management, and quality control of drugs used for the prophylaxis and treatment of opportunistic illnesses. In these ways, improved AIDS care can be expanded to reach more of those in need.