Doctors: African AIDS plans thriving

ADDIS ABABA, Ethiopia -- Only a few years ago, doctors from the Cambridge-based organization Partners in Health asserted that their AIDS-treatment programs in rural Haiti showed that people in even the poorest places could successfully take life-extending medicines. Few believed them.

But delegates at the second annual meeting of the US global AIDS program heard last week that new treatment programs for those infected with the deadly virus were being opened every week around sub-Saharan Africa, including in rural areas that previously had almost no health systems in place.

''People said the constraints were insurmountable, and we said it was not so," said Dr. Peter Mugyenyi, head of the Joint Clinical Research Center in Uganda. ''We're seeing lives being saved and infrastructure constraints overcome."

Mugyenyi, whose US-supported group now treats about 25,000 people around Uganda and is one of the largest AIDS-treatment programs in the world, described opening a clinic in Karamoja in the country's northeast.

''We flew in, and we couldn't find the airfield," Mugyenyi said. ''But we landed safely. There, it is most isolated. People are nomads. There was almost no health system, yet we now have 100 percent access" to antiretroviral drugs.

He said that if organizations have trained health workers, supplies of drugs, and experience in operating such centers, it is possible to start programs immediately -- anywhere.

In the town of Mubende, he said, his workers found a run-down government hospital overflowing with patients. The solution: Erect a large open-air tent.

''The next day we started," he said. ''The need is there. Now we work under the tent three days a week, and it is always full."

Gains are also being seen in rural southwestern Kenya. Dr. Eunice Obiero said the Keicho District Hospital had no AIDS clinic before the US President's Emergency Plan for AIDS Relief, a five-year, $15 billion effort that started in late 2003.

With US money, Obiero opened a clinic in April 2004. One year later, 1,128 people were enrolled, including about 500 who were put on antiretroviral treatment.

''We had many challenges," Obiero said, mentioning a crumbling 50-year-old hospital, a burned-out staff, and widespread malnutrition in the area.

But funding and innovation are leading to results. The clinic's staff has grown from five to 25 in a year, and they teamed up with Kenya's Ministry of Agriculture to start a 10-acre vegetable garden to give patients nutritious food.

The meeting here brought together 180 US officials working on AIDS programs and nearly 200 people who run US-funded projects around the world. It was designed to share best practices and problems in the first 18 months of the Emergency Plan for AIDS Relief.

Some attendees raised the issue of whether the rush to put people on antiretroviral drugs would sacrifice the quality of the program. By September 2004, the US effort had helped put 155,000 people on treatment, and officials believe the number has now exceeded its June goal of 202,000.

''Just by saying that Uganda, as a whole, has 50,000 people on treatment doesn't tell you anything about quality, and it doesn't say anything about adherence," said Dr. Christian Pitter, principal adviser for antiretroviral treatment for the US Centers for Disease Control and Prevention in Uganda. ''Ultimately, it's all about adherence, making sure people take the drugs. We can start all these people on anything we want, but we will fail and make things worse if they don't stay on treatment."

Antiretroviral drugs, which can add years to a patient's life, must be taken twice a day, every day. The pills are called triple-combination therapy because they contain a mixture of three drugs, which help reduce a person's resistance to the medicine but may contribute to such side effects as headaches and stomach pains. If side effects become too great, specialists say, patients might stop taking the drugs and a new mix of medication is needed.

Dr. Mark Dybul, deputy US global AIDS coordinator, said in an interview that he, too, is concerned about the quality issue. He said he plans to call in US government specialists on the domestic AIDS program to talk about it.

''When it comes to the drug issue, it's all about the quality of the program," he said.

In developing countries, anecdotal reports show that the rate of patients who stick to the drug regimen is ''higher than many US programs," said Dr. Michael Saag, director of the AIDS Center at the University of Alabama at Birmingham. One notable example is Partners in Health's Haiti program, which trains villagers to check on patients and has attained an adherence rate of nearly 100 percent.

Saag said that evidence from Zambia also indicates that program quality is high. After the first year of the US program in Zambia, he said, 85 percent of the sickest patients were still alive. Those people were defined as having levels of crucial immune cells called CD4s of under 50; guidelines call for treatment to begin when a person's CD4 count drops under 200.

Saag said that for those Zambians entering treatment with a CD4 count of between 150 and 200, 93 percent were still alive after a year. Both findings, he said, mirrored results of AIDS patients in the United States.

One major difference existed between the Zambia program and that of his AIDS clinic in Alabama -- the sheer volume of patients. Since 1987, when the University of Alabama AIDS clinic opened, 5,900 patients have received treatment. In one year, his programs in Zambia have enrolled 11,700 patients on antiretroviral treatment.

''What's happening in Zambia is breathtaking," he said in an interview at the conference. ''It's still a drop in the bucket to what is needed, but I'm stunned by how fast it has gone."

John Donnelly can be reached at donnelly@globe.com.