Washington

Conflict is brewing between clinicians treating AIDS patients and some public-health experts over the wisdom of distributing cut-price AIDS drugs rapidly in poor countries.

While hard-pressed doctors are trying to get the medicines out as quickly as possible, others warn that they may do more harm than good, diverting scarce funds from more cost-effective preventive measures and perhaps raising new problems with drug resistance and side effects.

“We have to ask what capabilities need to be put in place to make sure the problem isn't made worse,” says Tom Coates, director of the AIDS Research Institute at the University of California, San Francisco.

“Parachuting drugs into countries and saying, 'Here they are, go for it!' could do a considerable amount of harm in addition to the good we're expecting,” says Tony Fauci, director of the National Institute of Allergy and Infectious Diseases.

The warnings follow the decision last month by several leading drug companies to slash the prices of AIDS drugs for sub-Saharan Africa, home to 70% of the world's HIV-infected people (see Nature 410, 289; 2001). The new prices followed moves by generic-drug makers in India and elsewhere to defy patents and distribute AIDS drug cocktails in Africa (see Nature 409, 751; 2001).

These actions created an unprecedented momentum for the wide distribution of AIDS medicines on a continent where, just a few months ago, no one dreamt of broad access to expensive, life-saving therapies.

But some public-health experts worry that the arrival of more of the drugs will eat into crucial AIDS-prevention budgets. They also say that the infrastructure in many places will not support proper drug distribution, and that bad distribution and monitoring may give rise to strains of the virus that will resist known therapies.

Barry Bloom, dean of the Harvard School of Public Health, says AIDS drugs should be dispensed only under direct observation — a strategy that has worked for tuberculosis — and that may not only prevent resistance, but also stop black markets from developing.

These arguments inflame doctors and activists working with AIDS patients in poor countries. The warnings are reminiscent, they say, of the now-debunked criticism of widescale immunization initiatives a generation ago. Anne-Valerie Kaninda, a medical adviser to Doctors Without Borders (Médecins sans Frontières) in New York, says: “The limited experience of introducing anti-retrovirals [in poor countries] shows that there are solutions to the problems.”

One case study in particular backs up their argument. Four years ago the Brazilian government began providing free cocktails of three AIDS drugs. Despite an imperfect public-health system, the country's AIDS death rate has been halved. Last year, the number of new infections was half of that predicted by the World Bank in 1994.

“It's horribly difficult to make [drug distribution] happen. But it is possible,” says Ezio Santos Filho, a Brazilian activist whose group, Grupo Pela Vidda, has helped push for the programme. “What we cannot accept is the excuse that the regimens are just too difficult” for Africans. “We have to make these medications available by all means possible.”

The drug companies are playing down the effect their move will have without major infrastructure improvements. “There's a need for more AIDS specialists to make sure these patients take their medicines properly every day, so that we avoid resistance developing and the medicines are truly effective,” says Jeff Trewhitt, a spokesman for the Pharmaceutical Research and Manufacturers of America.

But advocates of access to the drugs point out that, even in the United States, adherence to complicated drug regimens is hardly a given: recent studies have shown that only two-thirds of people with AIDS take their medicine as much as 80% of the time. The number in Brazil is about the same, according to a 1999 government study, providing ammunition for those who say the real enemy of getting medicines to Africa is a lack of political will, rather than practical obstacles.

Hard to swallow: combination pills that make AIDS drug regimens easier to follow are on the way. Credit: AP

Proponents of widespread distribution also argue that the complicated drug regimens used in rich nations may not be needed in poorer countries. A pilot programme being launched in South Africa this month by Doctors Without Borders will have patients taking three pills twice a day, rather than the 20 or 30 tablets commonly taken in developed countries.

Follow-up tests will be administered less frequently than in the developed world, unless patients show visible deterioration. Ultimately, simpler and cheaper versions of the tests are expected to be produced. And combination pills that make drug regimens easier to follow are already being produced by some drug companies.

Eric Goemaere, the Doctors Without Borders doctor in charge of the pilot programme in Khaelitsha township near Cape Town, admits that this approach to monitoring has not been scientifically validated. “What we need to develop is a science for low-income countries,” he says. But he adds that he is not prepared to wait for that science to emerge before starting treatment. “We see [people] die almost on a daily basis. We feel a bit in a hurry.”