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For AIDS activists, these are vital times in Africa's desperate struggle against the disease. In South Africa, home to the world's highest number of infected patients, the week began with a Supreme Court hearing into a landmark case over government efforts to import cheaper generic drugs into the country.
The lawsuit--brought by pharmaceutical companies trying to protect lucrative patents on their anti-AIDS drugs-has since been postponed until Apr. 18. Nonetheless, the case underscored the developing price war over the cost of life-prolonging medication that is denied to the poor of sub-Saharan Africa. As infected South African protesters took to the streets to demand drug-price cuts, U.S. pharmaceutical company Merck announced plans to slash the prices of two AIDS drugs in developing countries. At the same time, Cipla, an Indian maker of generic drugs, asked South Africa to give it the right to sell eight AIDS medications at prices below those offered by the patent-holding companies.
Dr. Mark Cotton, a senior specialist and head of the pediatric infectious-diseases unit at Cape Town's Tygerberg Hospital, has daily contact with children who are dying because they cannot afford medication. He spoke with NEWSWEEK'S Arlene Getz about the latest developments. Excerpts:
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NEWSWEEK: Just this week Merck, a leading U.S. producer of anti-HIV medications, agreed to cut its prices on two important AIDS drugs. Cipla, an Indian maker of generic drugs, is also hoping to sell cheaper drugs to Africa. Will these offers have any effects on your work?
Mark Cotton: If they come through it may mean cheaper and more accessible medication. We are desperate for them-it would make an enormous difference to an unbelievable number of people.
Does anybody in South Africa have access to anti-retroviral drugs at the moment?
Access is entirely dependent on how much money you've got and if you've got medical insurance. More and more medical-insurance schemes are funding anti-retroviral therapy, so those people do have access to the medication. But I'd guess that covers only about 5 to 10 percent of those who need it.
What happens to the other 90 percent of those infected?
In terms of anti-retrovirals they get nothing. They are getting most other supportive care. [Some examples are] micronutrient supplementation, multivitamins, vitamin A. Oral candidiasis can be treated reasonably well. Recurrent bacterial disease can be treated with effective antibiotics. That we can do.
So you can treat the symptoms, but not the underlying disease?
Correct.
The lawsuit that began in Pretoria on March 6 was brought by drug companies who want to protect their patents by stopping the South African government from importing cheaper, generic AIDS drugs. Are their arguments valid?
Essentially I couldn't care [about the arguments], as long as we get the medication. If a formula is found that protects the patent rights and allows the patients to get access to the medicine, that's fine. But we really, really need the medicines. One of the good things about the case is that it focuses on the haves vs. the have-nots, and the have-nots are incredibly disadvantaged. Families are being absolutely devastated by this.
Even at the promised lower prices, treatment is still likely to cost a minimum of $600 a year per patient. Can South Africa afford that?
That's still a lot of money. But what [the price cut] will mean is that it might allow treatment for 50 percent of those who need it, instead of only 5 to 10 percent. So more people are going to benefit, and that's what we want. We need to learn how to use the medications more effectively too-to follow the Brazilian line, which is to wait until they show that they really need them.
How many HIV-infected children are you treating?
We have about 500 outpatients on our register and 10 to 15 who are sick in the wards at the moment.
How old are they?
The majority of them are under 3, but they vary from a couple of months to about 16.
What's their average survival time?
We're seeing that they're surviving longer and longer, even without medication, but we're not sure how far beyond childhood they're going to get. We have a lot of kids that do die early on, in the first year or two of life. Generally we get children who come in because they're sick, and if they come in sick under a year of age the average survival is two to three years after that. If they present after one year of age with symptoms of HIV they often can survive for four years or even more.
How long would they live if they got the anti-retrovirals?
We don't know. Anti-retroviral therapy has been around for about six years, and in that period it's dramatically reduced mortality [but] how sustainable that is we don't know. [Also,] we're not sure how child-friendly the preparations would be, how much in suspension form they would be, if we would be able to dose kids from these drugs. Having access to the drugs is the first thing we need. It's not the whole answer, but it's an important part of the answer.
What's it like being on the front line of the AIDS struggle?
It's very tough. We take comfort with small victories-getting a patient pulling through a difficult time; seeing them come to the clinic when they're still well and haven't started to deteriorate. In the same way when you're dealing with a patient with end-stage cancer, your role changes from someone who tries to cure it to someone who palliates it-that's what we do quite often.
How do you feel when you see these children coming in and know that treatment exists but you can't give it to them?
I guess we try not to feel, because if you open yourself to feeling you can't cope with it.
This is your sixth year in this position. Who was your most memorable patient?
There's a particularly dramatic episode of a little boy who's almost 5 years old now. About three years ago he had recurrent respiratory distress, difficulty breathing. On one occasion he came in very sick and he needed to be resuscitated and intubated-a tube needed to be passed into his trachea to help him breathe. There were no intensive-care beds in the entire region, and he had to take his chances in a general ward. He survived, [but] remained in the ward for about two to three months requiring oxygen. We ultimately convinced the hospital authorities that it would be worth purchasing a [course of] a single anti-retroviral drug for him, because that was all we could afford.... He was sent home and has now been with his mother for three years.
So one single course of medication bought the child an extra three years?
In his case we think it was associated with his dramatic improvement. Ideally one wants three different medications to attack the virus in three different cases, but we managed to get funding for one. We think it really made a difference. Just the fact that we could get him home to his family was a wonderful thing.
How much does this treatment cost?
About 120 rand a month-less than $20.
South African President Thabo Mbeki was widely criticized for suggesting that AIDS is caused by poverty rather than HIV. He also questioned the safety of anti-AIDS drugs. How did that affect your work?
It has been damaging. Not only to us, but to the country and to the people with HIV. I think that everyone accepts that HIV causes AIDS-even in government circles. On the ground and behind the scenes people are putting resources into it. The fact that there's this court case is proof that there's a very multilayered response to HIV. The case is highlighting the issues of cost and accessibility to medicines-a fundamental North-South issue.
Are patients better informed now?
Our patients have always tended to be passive. As a result of the kind of society South Africa has been, they've taken what's been given to them and accepted that as healthcare professionals we do our best for them. But that's definitely changing. Two weeks ago I had a mother who was extremely upset with us when she discovered that she had not been screened [for HIV] and she had not been given any anti-retroviral during pregnancy to reduce her chances of her infant being infected. The infant is infected and is end-stage-we don't think this child is going to survive much longer.
Shouldn't at least some of these tragedies be averted now that the government has started a program of offering free nevirapine to reduce the risk of pregnant women transmitting infection to their babies?
It's not like in America where you can send out a directive and the funds are there for the medication and the counselors and everything gets put in place very quickly. But I think the tide has turned and over the next couple of years the momentum will grow. I'm very confident of that.
The government program was started in January, but it only operates in some 18 clinics nationwide. What happens if a pregnant woman goes to public facility and asks to be tested for HIV?
She'd be referred to a site where intervention is taking place. Certainly the test can be done in virtually every clinic, and she could get hold of the medication [if she has] private means. Or she could be referred to a site where the government pays for it. It may be inconvenient but it is possible. [But only] a fraction of mothers have access to this, and they have to know to ask for it.
Do some people refuse to be tested because they know they can't get treatment?
Yes, we have people who say they just don't want to know.
Would that change if they thought they could get affordable medication?
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