On the other hand, the UNAIDS Initiative might be viewed as fitting in easily with Côte d’Ivoire’s health strategy. How is this Initiative designed, and for whom?
"Under the Initiative,[2] the ... developing countries involved in the pilot phase will work to adapt their health infrastructures to ensure effective distribution and use of the HIV/AIDS-related drugs, and participating pharmaceutical and diagnostic companies will subsidize purchases of these drugs." ([5] page 1.)
"To date, Glaxo Wellcome plc, F. Hoffmann-La Roche Ltd., and Virco N.V. have confirmed their intention to participate in the Initiative. Companies such as Janssen Pharmaceutica N.V., and Organon Teknika N.V. have expressed interest and are currently reviewing the level of their possible involvement. Discussions are also ongoing with others, and the Initiative is open to all those interested in participating." ([5] page 2.)
"... we must begin with small-scale pilot programmes, involving tough decisions to determine the limits of participation. But the alternative is to do nothing." (Peter Piot, [5] page 2.)
In each country, the following entities will be created:
- A national HIV/AIDS drugs advisory board, under the Minister of Health to devise a national policy, examine needs, optimize available resources, identify the selection of drugs that should be provided and the best ways of making these available to patients, set criteria for the participation of health centers in the Initiative and for the selection of patients, and draw up treatment guidelines.
- A nonprofit company to act as a clearing house for placing orders for products, acting as an import point for drugs, and for managing the subsidies from the companies. "The entity... will be funded by the pharmaceutical companies that use it, [and] will also address related business and logistical issues." ([5] page 3.)
Each company will negotiate separately with each country. "Companies participating in the Initiative will make available a range of HIV-related drugs, including antiretrovirals to combat the ... HIV infection, antimicrobials to prevent and treat opportunistic infections common among people with HIV/AIDS, and antibiotics to treat sexually transmitted diseases (STDs), which have been proven to increase the risk of HIV transmission. In addition, diagnostic companies will provide virological services and tests for patient monitoring." ([5] pages 3 and 4.)
The following will be the sources of financing:
- "Pharmaceutical companies will provide... drugs at subsidized prices."
- "Health Ministries will both create new sources of funding and build on existing programmes."
- "UNAIDS will provide US$1 million for oversight of the health advisory boards and non-profit companies, evaluation of the pilot phase, and the dissemination of recommendations for applying the... principles in other comparable situations." ([5] page 4.)
What are the criteria for inclusion in the UNAIDS Initiative, as implemented in Côte d’Ivoire? A workshop held in Abidjan in July 1997 seems to have reached the following consensus on the principles governing the selection of patients for treatment:
(1) Those falling into the following categories:
- "symptomatic, with a CD4 count of less than 500 per mm3, and classified in group C of the CDC classification (i.e. patients who have reached an advanced stage);
- "those that have recently undergone seroconversion (initial test results being negative and the second set of results being positive);
- "subjects in group A." ([6] page 7.)
The above division into categories indicates that the thinking on the subject was not very clear. Subjects in group A are hardly any different from patients who have recently undergone seroconversion; it is simply that the former are affected by the clinical signs of seroconversion.
(2) Those presenting no biological, hepatic, or renal anomalies (a biological assessment is therefore required, with a list of the specific forms of examination to be carried out).
(3) Those whose socioeconomic status can provide them with "the necessary financial resources and understanding of the disease and its treatment to enable them to comply with the treatment provided" ([6] page 8), socioeconomic status being determined on the basis of a social survey.
Naturally, the discussions at the workshop also dealt with the list of establishments that would provide care. The list is limited, of course, because of the standard of equipment and expertise that have to be brought together in order to provide the most appropriate form of treatment and ensure that patients are properly monitored. The consensus that had apparently been reached in July fell apart in November.
The technical constraints that result in only a few establishments being authorized to possess antiretroviral drugs (thus controlling all other establishments and prescribers providing treatment for patients on antiretrovirals) must, however, be reexamined in light of the information available to us regarding the catchment areas of health units in Côte d’Ivoire. Thus, a 1996 survey found that between 90% and 100% of patients in the centers and services examined (i.e. the Infectious Diseases, Pneumology, and Pediatric Sections of the Treichville CHU, the Marcory public clinic, the Anonkoua community health unit, the Abidjan ambulatory and counseling unit,[3] the San Pedro CHR, and the Bardo urban clinic in the Southwest region) are city-dwellers, and between 80% and 81% of those hospitalized in these units normally live in Abidjan ([1] III, page 2), indicating that geographical accessibility plays a role even in highly specialized services.
Consequently, the technical and economic context in which this Initiative is being implemented makes it fundamentally inequitable.
In the case of Côte d’Ivoire, estimates of the number of people who are HIV-positive range from 600,000 ([7] page 1) to 900,000 ([8] page 1). To the best of our knowledge, there has been no discussion in Côte d'Ivoire of how the UNAIDS drugs for treating opportunistic infections could be distributed. All attention is focused on antiretroviral drugs. "Declared cases of AIDS amount to about 5,000 per year, and it can be supposed that there is massive underreporting, and that the figure should be more like 20,000 cases per year. In terms of access to care, it can be assumed that between 5,000 and 10,000 AIDS patients alone could be identified each year, and could be potentially eligible for antiretroviral treatment." ([7] page 1.)
"If all patients who have reached an advanced stage of the disease (i.e. full-blown AIDS) are to be treated, regardless of their prognosis, we must expect a minimum of 5,000 per year (undergoing bitherapy or triple drug therapy). Such treatments improve survival rates, and if we assume that survival can range from two to four years at this stage of the disease, the total number of patients could increase as follows:
First year: 5,000
Second year: 8,750
Third year: 11,250
"In the absence of any precise information on therapeutic regimens, it is difficult to calculate the percentages of these patients following antiretroviral bitherapy and triple drug therapy. It can be reasonably assumed that triple drug therapy would be appropriate for at least 10%-20% of these patients." ([7] page 2.) Calculations by Dr. Anglaret (based on consultations for adult general medical care in the Southern region) suggest that bitherapy is indicated for about 61,500 patients (i.e. T4 between 500 and 300 per mm3), while triple drug therapy is indicated for about 27,000 (i.e. T4 lower than 200); i.e. more than the number of patients on triple drug therapy in France.
In addition, treatment is indicated for only a few patients who have been infected recently (i.e. within the last three months). "CNTS is the only place where such cases could be identified. There are estimated to be between 30 and 50 cases per year, and they require prolonged triple drug therapy. The duration of this has yet to be determined, but it should not be less than 18 months, according to the present state of our knowledge." ([7] page 3.)
"At present, prevention of mother-to-child transmission of HIV-1 is the only case in which single therapy seems advisable. Its effectiveness is currently being tested. In Abidjan alone, the number of pregnant women benefiting from this strategy (from four to six weeks of AZT) is about 11,000 per year." ([7] page 3.)
The above considerations relate to the use of antiretroviral drugs. No attention has been paid locally to what the UNAIDS Initiative could mean for the treatment of opportunistic infections; however, the number of patients potentially benefiting from the Initiative is only a fraction of the number for whom one could justifiably prescribe antiretroviral drugs. Selection for treatment will inevitably be based on socioeconomic status, and public health specialists must view this with repugnance.
Implementation of the Initiative has not, therefore, been prepared as carefully as it should have been, and moreoever it is difficult to avoid the conclusion that the Initiative itself is fundamentally unjust. Nevertheless, that will not prevent it from becoming an integral part of the country’s health strategy. The whole issue of treating patients with antiretroviral drugs might make it possible to avoid any sort of health reform. From a political point of view, it would be enough if a small number of handpicked patients were treated, because it would be easy to find medical arguments to justify the selection made. It would also be nothing new in Côte d’Ivoire for international assistance -- as well as national solidarity -- to serve primarily the interests of the higher-income groups.
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