Study finds AIDS drugs succeed in poor nations

BANGKOK -- The first large-scale study of HIV and AIDS patients receiving antiretroviral treatment in poor countries found that the vast majority improved remarkably, including many who had been near death, the group Doctors Without Borders said yesterday.

The study of more than 12,000 patients, released at the 15th International AIDS Conference, counters a view expressed by some officials that increasing the availability of AIDS treatment in the poorest places would fail in part because patients would not take their medicine as instructed.

The Doctors Without Borders report on its treatment programs in 16 countries found a two-year survival rate of 85.3 percent. About 40 percent of the patients began treatment with a prognosis that they would die within a year, based on CD4 counts below 50. CD4 measures a body's ability to fight off diseases; the World Health Organization recommends antiretroviral treatment for patients with a measurement below 200.

But after a year of treatment, the patients' CD4 median gain was 135, and their two-year rate was 208, a turnaround that Doctors Without Borders clinicians said was similar to gains among patients in rich countries such as the United States.

Smaller studies, such as those done in Haiti by Cambridge-based Partners in Health, have found similar survival rates, but none has been based on such a broad sampling of patients in developing countries.

An estimated 440,000 people with AIDS are being treated in poor countries, or only about 7 percent of those who need the drugs. One central goal of the AIDS conference in the Thai capital is ''access for all" to treatments widely available in rich nations but scarce in poor countries, especially those in southern Africa where the pandemic is hitting hardest.

Doctors Without Borders was able to greatly expand its treatment programs in large part due to the simplification of the drug regimens in the past several years. At the conference, group officials said that about 78 percent of its patients now take a triple-dose combination pill twice a day, compared with more complex combinations of several pills two or three times a day. The findings have been issued three years after the head of the US Agency for International Development, Andrew Natsios, said the scale-up of antiretroviral treatment would be inadvisable for patients in Africa because many Africans ''don't know what Western time is."

Dr. Alexandra Calmy, an HIV adviser based in Geneva, said: ''It's possible to treat large numbers of patients in one place. It's easy to use, but adherence and management still present some problems. There are still many challenges that need to be addressed."

One obstacle is the lack of inexpensive, backup antiretroviral drugs in case a patient does not respond to the initial treatment. Daniel Berman, of the doctors group's Campaign for Access to Essential Medicines, said the average price for the initial line of treatment is about $350 a year per patient, compared with about $3,000 a year for the next line of drugs.

''We think it's a crisis," Berman said of the cost of the second line of drugs. ''Drug companies need to lower their prices."

Between 2 percent and 6 percent of Doctors Without Borders patients are on the second line of drugs. Calmy said that more patients are likely to need those drugs in the coming years as the disease advances in their bodies, and that some others may be developing resistances that are still undetected. She said the group lacks proper diagnostic tools to learn about resistances to medication at an early stage.

In the Lusikisiki district of South Africa's Eastern Cape, one of the poorest areas of the country, Dr. Hermann Reuter of Doctors Without Borders supervises 236 adults and 15 children on antiretroviral drugs, or ARVs. Of the first 12 who started last year, each has gained 18 pounds on average.

''ARVs are easy," he said. ''The choice is, are you going to let people die or give them the ARVs? It's easy to give them the ARVs."

The more difficult problem in Reuter's district, which is a four-hour drive south from the Indian Ocean port city of Durban, is its severe shortage of health workers, he said. His health centers have 35 nurses, and 37 nursing vacancies.

Still, he said, the successful start of his group's AIDS treatment program late last year offered a morale boost for the nurses. He thinks the program also has helped strengthen the health systems in the rural area.

''It made the nurses enthusiastic," Reuter said, adding that the nurses now prefer to work with the patients taking antiretrovirals because they are responding well, and the nurses leave the other patients to him to cope with.

Many patients also have volunteered to work at the health center. And members of the Treatment Action Committee, or TAC -- South Africa's network pushing for universal access to treatment -- have started closely monitoring the clinics' pharmacies to make sure that drugs do not run out.

Reuter said one district health manager initially rejected the TAC's monitoring, considering it interference, but grew to welcome it as the best source of information on drug shortages.

Also at the conference yesterday, dozens of protesters held large posters with photos of the Group of Seven leaders, including President Bush. They splashed red paint over the leaders' faces, symbolizing blood for the deaths of millions of people from AIDS.

The protesters announced amid loud whistle-blowing that they were making citizen's arrests of the seven for various offenses, including not living up to pledges to fully fund initiatives to fight AIDS.

The Bush administration says it has put record amounts of money toward the global fight against AIDS, pledging to spend $15 billion over five years.

Brook K. Baker, a law professor from Northeastern University who participated in the protest, said America's ''fair share" -- based on its percentage of the world's gross domestic product -- should be $30 billion over five years.

Baker also criticized the Bush administration for its stands against immediately accepting generic drugs and the reluctance to buy condoms for prevention programs that are aimed at the general population in developing countries. White House officials want the drugs to be reviewed by the US Food and Drug Administration and have targeted condoms for ''high-risk" populations, such as sex workers, truck drivers, and injecting drug users.