Hope In Sight For AIDS Sufferers

For each one of the still small number of Pacific Islanders killed by HIV-AIDS, many more are living with the disease.

Papua New Guinea...AIDS epidemic overwhelming the country.

There's no cure for AIDS, but for those with access to antiretroviral pills life becomes bearable and prolonged.

The great drawback is the cost. In Europe and America, where the disease has impacted heavily for 20 years, the cost of the pills that had to been taken in large numbers several times a year could be US$15,000 a year, or more. That would be an impossible burden for Pacific Islanders or for their governments to subsidise.

The disease impacts mercilessly not just on individual sufferers but the families and societies faced with the cost of supporting them. In Papua New Guinea, the first cases of children orphaned by AIDS deaths of both parents are appearing.

In Fiji, a project likely to become a pilot for the Pacific is cutting the monthly cost of treatment from F$2000 (US$1060) to under F$300 (US$159). The reduction brings treatment within the reach, or not out of the realm of possibility, to many more Pacific Islands sufferers, but still leaves the majority beyond it.

With the probable exception of Papua New Guinea, where an AIDS epidemic is overwhelming the country, incidences of the disease elsewhere indicate that Pacific governments could climb the cost barrier to bring massive relief, though not a cure, to those of their people in need of it.

In Fiji, efforts initiated by the non-government AIDS Task Force backed by the government pharmacy and civil society HIV networks overseas, have just slashed the cost of antiretrovirals by ten folds to F$250 a month.

In September, the AIDS Task Force of Fiji launched a project with the Ministry of Health's sexually transmitted diseases clinic to supply free antiretroviral treatment to another 20 people in urgent need of the treatment for their HIV infection.

According to the Task Force's director, Jane Keith-Reid, the project could become a pilot for countries like Kiribati, where the risk of an AIDS epidemic is serious due to the exposure of overpopulated atoll societies being infected by the disease by some of the local seamen working on foreign ocean-going ships.

The antiretroviral project beginning in Fiji opens a door through which Pacific Islands governments could use foreign aid and the United Nations-sponsored Global Fund, set up in January 2002, to bring antiretroviral therapy (ART) within the affordable reach of patients. The Fund is also intended to attack two of the world's greatest killers‹malaria and tuberculosis.

The Fund, according to a September statement by the United Nations Secretary-General, Kofi Annan, still only half way to the US$10,000 million a year needed from 2005, has allocated the Pacific Islands US$6 million a year for their fights against HIV-AIDS, malaria and tuberculosis.

At a meeting being held in Fiji in October, a government and a non-government organisation representative from each island country will discuss a budget for using the money drafted by the Pacific Community. A work plan is under preparation.

Dr Rob Condon, medical officer/epidemiologist at the World Health Organisation office in Suva, says the Global Fund's annual US$6 million will be shared equally by the region's malaria, tuberculosis and HIV-AIDS campaigns. But only some of HIV-AID campaign funds can be used for antiretroviral purchases.

While the purchase of pills, probably from pharmaceutical manufacturers in India and Brazil, is a relatively straightforward issues, the cost of distributing them effectively and safely and avoiding patent rights complications are other hurdles to be surmounted.

"The whole issue is patents legislation, trade rights and free trade and that sort of thing," he says. "Medicines are subjected to patent rights and intellectual property agreements, but the price of medicines as dictated by the agreements has big implications on access. Some countries have patent laws that give them a clear way forward as to how to deal and still remain onside with the World Trade Organisation and financial heavyweights. "Others don't have well developed laws. The question is should Pacific Islands countries defer to the laws of a regional trading power like Australia, New Zealand or whoever, or develop their own legislation."

WHO will supply the Fiji Ministry of Health with a patent law expert and an HIV-AIDS policy expert to look at the legal framework existing in Fiji, which is likely to be representative of what's available in the Pacific, and develop strategies to give Fiji and other Pacific Islands access to be best available cost-effective medicine.

One strategy is parallel importation; if a manufacturer has patented a product in several countries it may sell it at different prices in different countries. If the price in country A is much lower than in country B, a country B importer can buy it at the cheaper price from A and sell it in B for less than the price set by the patent holder.

Condon says a requirement of the Global Fund is for the strengthening of laboratories in the region. There will be key labs for the process like a biology lab in Fiji, with capacity to monitor things like viral load to determine when you kick in treatment, or kick over to an alternative treatment.

"Lab testing capacity in the region now is not very good; most countries have access to rapid diagnostic tests that with a reasonable accuracy can tell you if someone is likely to be infected with HIV, but it is not a definitive test. You can't identify sub-types or be 100 percent whether a person is HIV positive. It needs to be double checked."

Another matter, Condon says, is "how a country will define eligibility for treatment and how those people will access treatment? Will it be done only through specialist clinics, or through primary health care clinics? What kind of technical monitoring of the dispensing of those drugs is going to be in place? What mechanism for taking treatment is in place?" A problem in Africa is people discontinuing when they feel better. That breeds resistance to the virus and makes that drug less useful. With tuberculosis, people take treatment by Directly Observed Treatment (DOT). That means a third person needs to witness people taking the drugs; just because their cough is getting better doesn't mean they stop taking the treatment.

"It may be easier to monitor in the Pacific, but we are going to need to strengthen these networks, and this is where governments will have to say this is how we are going to distribute these drugs'. We will link it with existing networks or, if they are not strong enough, we will need to strengthen them."

Since ART therapy was initiated, the number of pills taken, and the number of times daily taken, have fallen sharply as pharmaceutical companies discover ways of bundling several antiretroviral drugs into one.

The therapy may cause unpleasant side effects and it is essential that recipients have clinical management of their drug therapy by trained medical practitioners, the Fiji Task Force says.

"ART is not easy, it takes personal strength and commitment, and some people cannot tolerate the side effects, so it is not for everyone."

While relief from, but not a cure for HIV/AIDS is in sight, what matters most, the Task Force stresses, is that the first priority for attacking HIV/AIDS in the Pacific Islands must be prevention. That means constant education to impress on Pacific Islanders the nature of the disease and how to avoid it.

In 1996, the United Nations warned that all 22 Pacific Islands countries would be devastated by "one of the greatest tragedies of our time" unless their governments immediately move to attack the AIDS threat. By June 1995, only 234 cases had been reported in the region compared with 1.17 million globally. Now, more than 20 million are estimated to have died globally.

It was not until their meeting at Auckland last August, that Pacific Islands Forum leaders finally addressed the problem. They asked for a regional strategy for combating the disease to be put to them at next year's meeting in Niue.

There are about 4000 reported cases in Papua New Guinea and about 110 in Fiji, where the official forecast is that there could be 11,000 cases by 2015. Other Pacific countries have reported just a score, a dozen or so, or just two or three.

Stuart Watson, who after working for Australia's aid agency in Papua New Guinea for 15 years, is now UNAIDS co-coordinator for the World Health Organisation in the Pacific, says: "The picture we have of official cases in Papua New Guinea is only around 4000, but the general rule is multiply that by 10 and I would say that is probably the case throughout the region."

With a statutory National AIDS Council and since a comprehensive AIDS care and management act, "the PNG Government is one of the better countries in the region in recognising they have a problem," he says.

"A strong commitment unfortunately has not been transmitted into significant financial support for the national council."

Watson says the Pacific Islands are still "definitely a low prevalence part of the world," and that apart from Papua New Guinea it is still at the stage where AIDS can be managed.

"We know from the experience of high prevalence countries that have been dealing with it for a while, like Thailand and Uganda, that where there is support from government, where there is recognition that it is a multi-sectoral social issue, and where there is strong commitment to promoting preventative measures like condom use, that the rapid increase in infection rates can be slowed or reversed."