Sending HIV Drugs to Developing Countries
Recycling HIV drugs -- the practice of collecting and transferring unused drugs from one patient to another -- is becoming increasingly prevalent. Individuals often act independently, but community-based organizations are also involved in sending drugs to developing countries. On April 29, 1998, GMHC, in collaboration with more than a dozen local, national and international organizations, held a forum entitled "Recycling HIV Drugs for Developing Countries: Ethical and Practical Considerations" to discuss the implications of this practice.
Implications of Recycling
The practice of drug recycling began almost simultaneously with the onset of the AIDS epidemic in developing countries. Networks of friends and relatives responded to an urgent need for treatments by taking matters into their own hands. Initially, recycling almost exclusively involved drugs for opportunistic infections (OIs), but expanded to include antiretrovirals as they became available.
The very nature of drug recycling has serious medical implications, especially in regards to antiretroviral therapies. Recycling relies entirely on donations from people whose prescribed drugs became unusable due to death, side effects or treatment failure. This makes for an unstable supply that may lead to the promotion of drug-resistant HIV strains. Because some of the recipients of these medications are not receiving medical supervision, the risks for wrong dosing, drug interactions and dangerous side effects are too great to ignore.
Individuals and organizations send anywhere from a few pills to a few months' worth of anti-HIV and OI medications overseas. Organizations tend to have a more structured approach to the collection and distribution of drugs and also tend to partner with other organizations in receiving countries. Individuals usually respond to individual requests and are less standardized in their methods. Since there is no established procedure for drug recycling, there are no guidelines or controls. One of the goals of the forum at GMHC was to start a dialog between groups and individuals that have been involved in the practice but have not been working in unison.
Although many informal recycling efforts operate without ensuring that drug recipients have proper medical supervision, two organizations that have implemented drug recycling guidelines are AID for AIDS in New York and Union Positiva in Miami. Each of these groups supplies about 100 "clients" or "patients." As representatives of both organizations explained at the forum, they are careful about expiration dates and the time since the prescription container was first opened. Both organizations emphasize continuity of supply, and limit the number of patients/clients in order to guarantee a steady flow of medications.
Shipments are made once a month to patients who have provided a prescription from a physician in their respective countries. Often, the patients receive certain drugs that are unavailable to them, but are required to complete a particular combination regimen. The clients are enrolled in the program through community organizations in Latin America, which help to ensure stability of supply and proper medical supervision for the recipients of the medications.
Drugs in Developing Countries
Rosamund Lewis, M.D., of Doctors Without Borders, spoke about the conditions in developing countries. Even if basic health care infrastructure and universal coverage exists, such as in Cuba and many other Latin American countries, the cost of anti-HIV drugs is prohibitive, despite policies of providing some antiretroviral therapy. Such is the case in Mexico, where most patients receive dual therapy with nucleoside analogs but often at reduced or incomplete dosages. But in sub-Saharan Africa, wars, refugee crises and natural disasters frequently make it all but impossible to provide antiretroviral therapies to those with HIV/AIDS.
Dr. Lewis is looking specifically into how these conditions affect the implementation of AZT protocols for the prevention of mother-to-child transmission of HIV within Doctors Without Borders' programs in Thailand and Africa. The objectives of this project are to evaluate the practical aspects of providing AZT to pregnant women and to determine whether it is applicable in other countries and programs.
One of the difficulties of such a project is identifying and enrolling HIV-positive women. The social implications of testing HIV positive include potentially compromising domestic relationships and the possibility of discrimination by other members of the community. Once HIV-positive pregnant women are enrolled, they will be offered a short AZT regimen during the last month of pregnancy and no further antiretroviral therapy after delivery. The main shortcoming of this protocol is that the benefit to the woman's health is miniscule since a short course of AZT will not alter the progression of the mother's infection. However, women will receive complete prenatal care.
There is also the possibility that the newborn will be infected through breast-feeding. Unfortunately, if the mother avoids breast-feeding she may be stigmatized. Worse, bottle-feeding under poor sanitary conditions may expose the infant to bacterial infection through contaminated water. Overall, the distribution of antiretroviral therapies in poor, developing countries with inadequate health care systems, unhygienic conditions, and severe social problems presents overwhelming obstacles. Initiatives such as HIV drug recycling and the UNAIDS pilot program (see preceding article) are only small steps toward a global solution.
This article was provided by Gay Men's Health Crisis. It is a part of the publication GMHC Treatment Issues. Visit GMHC's website to find out more about their activities, publications and services.