In many developing regions of the world, the high cost of the new antiretroviral (ARV) drugs has been a near-unbreachable barrier to governments struggling to care for their HIV-infected citizens. In the poverty-stricken nations of sub-Saharan Africa, for example, public health programs are so underfunded that health agencies cannot afford inexpensive medications for opportunistic infections, much less the thousands of dollars it can cost to treat a single patient with ARVs.
Increasingly, though, countries with stronger economies are devising strategies to provide ARVs to those who need them. While a comprehensive combination therapy program is still beyond its means, Thailand now dispenses AZT to pregnant women with HIV to curtail perinatal transmission. Even more impressive are the efforts of several Latin American countries including Brazil, Argentina, Colombia, Costa Rica and Mexico that are working both individually and collectively to make ARVs a standard treatment option for their citizens. Many of the ARVprograms that have emerged in the region were born of tireless advocacy by grassroots organizations seeking to convince health officials that these medications could be made affordable and accessible through government intervention.
Improving Access, Improving Infrastructure
Brazil, burdened with a severe HIV epidemic, has created one of the most extensive ARV programs on the continent, providing double and triple combination therapy free of charge to some 58,000 people with high viral loads or full-blown AIDS. National legislation guarantees access to these medications for all affected Brazilians who are covered by the social security system (a parastatal organization that provides health care to private and public sector employees and their families) and to all HIV-positive pregnant women and their newborns. With funding from its own treasury and a World Bank loan, Brazil's projected 1998 budget for ARVs and monitoring will top $545 million. Many credit the two-year-old program for the dramatic 32 percent decrease in AIDS-related mortality in São Paulo state one of Brazil's highest HIV prevalence areas between 1996 and 1997.
"Brazil has worked hard to put together the kind of comprehensive system required to make a large-scale antiretroviral program successful," said Dr. Carlos del Rio, associate professor of medicine at Emory University School of Medicine and former director of Mexico's AIDS control and prevention program. "It has created national networks for drug supplies and lab facilities and put a lot of time and effort into making it all work."
As in Brazil, Argentina's ARV program owes its existence to the passage of a federal law that provides the most advanced drugs available to HIV-infected citizens through the national social security system. But the Argentinian program goes a significant step further in its creation of a special fund to pay for ARVs for those not covered by social security -- street vendors, small businesspeople, the unemployed -- and for low-income pregnant women. Some 11,000 HIV-positive Argentinians receive ARV therapy through these two sources and through private insurance plans.
But the process of setting up this program in Argentina was not simple. When the program first began, its managers discovered that they could not rely on the existing national drug delivery system to handle the complex job of distributing multiple therapies and to guarantee their consistent availability.
"With several expensive drugs being dispensed simultaneously, we needed a new system," said Dr. Laura Astarloa, director of Argentina's National AIDS Control Program. "We needed new computers, new computer programs, and new staff dedicated exclusively to tracking and distributing the medications, or else the program would not have succeeded."
High Costs and Cost-saving
In fact, infrastructure improvement can be a major expense for nations that embark on ARV programs -- and it often entails much more than a more efficient distribution system. Enhanced laboratory capability is essential to follow the progress of patients who receive the medications and to determine whether virus strains have developed resistance to certain drugs. Clinic and hospital staff must receive extensive training in order to prepare patients to follow difficult drug regimens and to monitor their progress. In some countries, conditions are so poor that a complete overhaul of the infrastructure would be necessary before ARV therapy could be successfully introduced.
"Examining these issues is all part of determining the benefits of instituting an ARV program in each country," said Dr. Rafael Mazin, regional advisor for HIV/AIDS and STDs at the Pan American Health Organization (PAHO). "How much must be invested to bring capabilities to necessary levels?"
Although they must shoulder these expenses, large countries such as Brazil and Argentina have also found ways to control some of the costs of their programs. Negotiating bulk prices with the pharmaceutical firms that manufacture ARVs helps make these drugs much more affordable. For example, Argentina now pays 33 cents for AZT pills that once cost $2 each.
The Horizontal Technical Cooperation Group (HTCG), made up of national AIDS program directors from several Latin American countries, wants to see that kind of price break made available not only to countries that can buy in quantity but also to smaller nations that are currently paying premium prices for their ARVs. Even though the members of the group are for the most part unable to buy these drugs together -- national regulations make such joint purchases difficult unless the countries involved already collaborate in a trade agreement -- the HTCG hopes to convince drug companies to offer lower prices as standard throughout the region.
"Uruguay is paying six to seven times what Argentina pays for the same medications because they have only 100 patients," said Dr. Astarloa. "This kind of inequality should not exist between countries."
Another proposal would create a revolving fund, administered through PAHO, that could loan money for ARV programs to Latin American countries that cannot afford the medications without financial help. But securing sufficient seed money to get the fund started has been difficult.
"Our estimates of the amount needed to undertake this are so high that identifying potential sources for funding is a real challenge," said Dr. Mazin.
Involving the Private Sector
While Mexico cannot afford to consistently offer triple combination therapy to all HIV-positive citizens, Mexicans with HIV/AIDS who participate in the nation's social security system are eligible for monotherapy or dual therapy. Pregnant women receive AZT to prevent transmission of the virus to their fetuses and newborns and, after they deliver, are eligible to receive triple therapy, as are all children under 18.
For the 50 percent of Mexicans not covered by social security, publicly funded access to ARVs has been nonexistent -- but not for much longer. This year, Mexico's National AIDS Control Program worked with university researchers to develop a new funding model to cover the medication needs of HIV-positive members of this huge segment of the population. With seed money from the government, FONSIDA will operate as a nongovernmental organization, soliciting donations from a wide diversity of sources -- notably, the private sector.
"We expect to involve industry, banks, community organizations and international donors in our fund-raising drive," said Dr. Griselda Hernandez, deputy director of CONASIDA, Mexico's national AIDS prevention and control program. "Perhaps we can serve as an example to other countries with limited resources that are seeking ways to expand treatment to all."
The Mexican program has made a significant investment in improving lab capacity in four states and in training medical personnel. It continues negotiations with pharmaceutical companies for lower bulk prices on drug purchases. Upgrading the national drug distribution system is also on the agenda.
"Although the program in Mexico has a way to go to reach 100 percent access, it's actually quite remarkable how much has been achieved in such a short time," said Dr. del Rio.
The Power of Advocacy
In most of these countries, the initiative behind ARV programs grew out of the activities of advocacy organizations and support groups for people living with HIV. Although these groups are generally smaller than their counterparts in North America and Europe, they have had an enormous impact on national treatment policies in Latin America.
In Costa Rica, the national health care system did not offer combination ARV therapy when the drugs first became available. After months of negotiation between the Costa Rican social security system and a committee of nongovernmental organizations and groups representing people with HIV, activists helped an HIV-positive college student file a petition with the Supreme Court asking for triple combination therapy that he could not afford but that could save his life. The justices ruled in his favor, and although he died less than a month after their decision, his courage prompted more than a dozen others to present their own petitions. Within a few weeks, the Court ordered the national social security system to develop a plan for delivery of these medications to Costa Ricans with AIDS. Activists in Panama, inspired by the victory in Costa Rica, plan to file similar petitions with the Panamanian Supreme Court.
"Advocacy is alive and well in Latin America, and it's a very powerful force in this process," said Dr. del Rio. "Whether in Brazil or in smaller countries, the new laws and policies that guarantee access to antiretrovirals are due to the activities of these groups."
Elsewhere in Central America, resource-poor countries such as Honduras which has more than half the reported cases of AIDS in the region offer no ARVs to their citizens. People with HIV in Honduras who take combination therapies either pay for them themselves or are enrolled in drug trials conducted by pharmaceutical companies. Activists in Honduras continue to lobby for improvements in national treatment policies and for government funding of ARV therapy.
In Nicaragua, activists have become directly involved in the treatment process itself. The country's only ARV program is operated not by the financially constrained government, but by a nongovernmental organization, the Fundación Nimehuatzin, and a team of health professionals based at a public hospital, Hospital Manolo Morales, in Managua. With support from the private sector, foundations and international donors, NGO and hospital staff have managed to provide 30 patients with ARVs. They closely track both the medical progress of the patients and all expenses to enable them to build an argument for the cost-effectiveness of ARV therapy.
"Our aim is to be able to prove to the government how important it is to provide this kind of medication and how it can cut costs in the long run," said Rita Arauz, president of Fundación Nimehuatzin.
-- Margaret J. Dadian
