Just 18 months ago, Suzana Murni Spiritia, a 24-year-old graphic artist living in Jakarta, Indonesia, tested positive for HIV, the virus that causes AIDS. After giving her the grim news, Spiritia’s doctor recommended that she take the antiviral drug AZT to slow the virus’s steady assault on her immune system. But Spiritia faced a crisis—there was absolutely no way she could afford the treatment. “How am I going to take AZT when it is going to cost more than I make?” she asked. Denied access to the therapy, Spiritia, now a member of an international advocacy group, is fortunate enough to still be symptom free. But during the eleventh International Conference on AIDS in Vancouver last week, she recounted how, before she set off for Canada, a friend in Jakarta asked her what the meeting’s official theme was going to be. “I said, ‘One World, One Hope,’ ” she recalled. “And he said, ‘No it is not. It is Third World, No Hope.’ ”
Similar refrains were heard throughout the five-day conference. With 15,000 delegates from 125 countries, it was the largest such gathering of its kind ever held. And ironically, even as Spiritia and others bemoaned a lack of access to affordable treatment, medical researchers and pharmaceutical companies announced some promising new breakthroughs. For the first time ever, they unveiled data showing that a new class of drugs, called protease inhibitors, significantly reduce so-called viral loads—sophisticated measures of the level of HIV in the body—when used in tandem with other previously prescribed antiviral agents. Spokesmen cautioned that the data is preliminary—and the length of the treatment’s effectiveness in not yet known. But in some cases, viral load even dropped below detectable levels, leading some to predict that victory in the battle against AIDS may soon be won.
The big winners, contend the critics, will not be people like Spiritia. Instead, they will be the multinational pharmaceutical companies, whom they accused of profiteering from the global epidemic. The drug companies have steadfastly refused to open their books, arguing that their profit margins for specific product lines is confidential. They insist, however, that their prices are fair given the high overhead—and emphasize that a significant portion of earnings are redirected into needed scientific research.
Perhaps so. But a month’s supply of Hoffmann-La Roche’s saquinavir, sold under the brand name Invirase, the only protease inhibitor currently available commercially in Canada, costs $645. When added to other drugs needed in the new combination therapies—or “drug cocktails” as they are now called—the price of treatment can reach $15,000 per year. That is clearly out of the reach of anyone not covered under private insurance or government drug plans. But even more importantly, observers point out, the new drugs are virtually useless to the vast majority of the world’s 21.8 million men, women and children now living with HIV and AIDS—94 per cent of them in the developing world. “If we had to pick a hot topic for this week,” observed the Clinton administration’s national AIDS policy director Patsy Fleming during the Vancouver meeting, “it would be, yes, we
have new protease inhibitors and viral load tests—but it is who is going to get them that matters.”
Such issues are almost certain to dominate the AIDS debate for many years to come. “While we have seen important advances in our understanding of basic science, of the epidemiology of HIV infection, and of novel approaches and technologies for care and treatment of people living with HIV and AIDS, we have nonetheless witnessed the unabated progression of the epidemic in country after country around the world,” observed Brazilian delegate Richard Parker, chair of the department of health policy and institutions at the State University of Rio de Janeiro’s Institute of Social Medicine. And UNAIDS, the United Nations AIDS program, estimates that, by the year 2000, as many as 40 million people worldwide will be infected. “While the development of new technologies for prevention and treatment must be an urgent priority,” added
Parker, “it can never be effectively carried out or delivered outside of, or apart from, a more broad-reaching political response to the epidemic.”
There are plenty of politics still to come, if the Vancouver conference was any indication. Chanting “Greed Equals Death,” and “Access for All,” the U.S.-based activist group ACT UP condemned several drug companies for profiting from the illness. They awarded four of them their so-called Golden Urn award, which allegedly contained the ashes of people who had died of AIDS. “We are not opposed to drug companies making profits,” ACT UP member Stephen LeBlanc of San Francisco told Maclean’s. “But when it comes to AIDS, a lot of companies have an all-the-market-can-bear policy. The vast majority of people with HIV have no hope for access.” Filipino delegate Michael Tan of Manila’s Health Action Information Network, a nongovernmental educational and social research group, said that in his country AZT costs the equivalent of $8 a day— while the daily minimum wage is only $6. Asked if there was any positive news he could take home from the Vancouver conference, he smiled. “I think the good news is that the First World is finally beginning to realize that we have a very different situation in the Third World,” he replied. ‘We hear all this stuff about protease inhibitors—and go back and feel bad that we can’t even afford the older generation of drugs.” Others at the conference questioned the overall direction of AIDS research—and called for governments and private industry to fund more research into vaccine development. “The world would save a lot of money by preventing infections rather than waiting until they occur,” said Margaret Johnston, scientific director of the International AIDS Vaccine Initiative, a New York-based group launched in January with the backing of the
Activists say medical breakthroughs will make big winners of the drug companies
Rockefeller Foundation, UNAIDS and other organizations. According to Johnston’s group, only eight per cent of total AIDS research is devoted to vaccines, even though scientists agree that, problems aside, they are both theoretically possible and desperately needed. The reason, contends Johnston, is economic. “The market incentives for companies to get involved in vaccine development have not been adequate,” she said, calling on governments, pharmaceutical companies and philanthropic organizations to rally to the cause.
Many argue that only vaccines can stop the tide of AIDS in the developing world. But there are also accessibility issues closer to home. During the conference, a new national coalition called Wake Up Canada targeted the federal health department’s exhibit booth, condemning the fact that only one protease inhibitor—Roche’s saquinavir—is commercially available in Canada while approval is still pending for two others: Merck’s indinavir, which sells under the brand name Crixivan and Abbott’s ritonavir, sold as Norvir. And activists also point out that most provinces—with the exception of British Columbia and Saskatchewan—do not yet universally fund the cost of recently developed HIV drugs. ‘We are a long, long way from having a solution to this crisis,” said Glen Brown, director of programs and services for the Toronto-based Community AIDS Treatment Information Exchange. Added AIDS Vancouver spokesman Philip Hannan: “Access is not just an issue in developing countries—it is in Canada, too.”
Several hundred Canadians are currently receiving the yet-to-be approved drugs under a compassionate access program. And Patrick Hanrahan, a manager for Mississauga, Ont.-based Hoffmann-La Roche Ltd., said his company has been working with both the provincial
governments and the AIDS community to ensure that saquinavir gets to those who need it. For one thing, Roche is consulting with provincial governments in an effort to get saquinavir included in drug plans. “These drugs are having a significant benefit on survival and on prevention of the disease,” he said. “A lot of the governments recognize that and are working together with Roche to make sure they are putting appropriate funding in place to ensure that if there is any patient in Canada who can benefit from saquinavir therapy, that they get access to it.”
But for those still in need, especially in the developing world, the words have a hollow ring. Brazil’s Parker, speaking during one of the conference’s plenary sessions, said that the “One World, One Hope” theme actually posed delegates with a challenge—“building one world out of many, of responding to the epidemic in ways that will ultimately overcome the gaps that seem to divide us.” He added: “How we respond will write the history of the epidemic in years to come.” That response, as was evident last week, is a long way from being clearly formulated.
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