Sunday Times (Johannesburg) - September 7, 2003

The New York Times reported this week that some doctors, politicians and pharmaceutical executives have argued that it was unsafe to send millions of doses of antiretroviral drugs to Africa - because incomplete pill-taking would speed up the mutation of drug-resistant strains that could spread around the world.

Such a danger exists: almost 10% of all new HIV infections in Europe were resistant to at least one drug or another.

But, the newspaper noted, the issue was particularly touchy in Africa - because it was tinged with racism.

The Times noted as an example, the outcry sparked when a US Agency for International Development director remarked in 2001 that Aids drugs "wouldn't work" because many Africans don't use clocks and "don't know what Western time is".

But surveys in Botswana, Uganda, Senegal and South Africa have found that, on average, patients took about 90% of their medicine.

The US average was 70% - and the figure was worse among the homeless and drug abusers.

The newspaper also said that complying with required dosage was getting easier.

Indian and other drug-makers, for example, were now making triple-therapy cocktails which came in as few as two pills a day - a more convenient treatment which was not yet available in the US because of patent regulations.

Doctors have claimed that most African patients were zealous about their regimens - and were more truthful when estimating their adherence.

Dr David Bangsberg, a professor of medicine at the University of California in San Francisco, told the Times that, on average, patients in the US told their doctors they were doing 20% better than they really were.

But a study of 29 Ugandan patients found that, on average, they estimated that they were taking 93% of pills - and were found to be taking 91%.

Although poor, with most of their countrymen earning less than $50 a month, Ugandans would rigorously adhere to taking their $27-a-month, Indian-manufactured twice-a-day, three-drugs-in-one pill.

In many such cases, one US doctor who has worked in Uganda told the Times the whole extended family, possibly with several infected members, would chip in so that one member would be saved to care for the children.

The doctor said: "If the whole family is pooling its resources to pay for you, you damn well better take your drugs. That's a whole different scenario from the US, where patients get free medicine and, if they change therapy, will let a month's worth go to waste."

Several doctors in Africa said their patients were highly motivated because they had seen friends or family die.

Most come in only when deathly ill, so the drugs seem to perform a miracle, making them well enough to go back to work. And even $1 a day is a lot, so they treat it as "an investment", said Dr Elly Katabira of Makerere University Medical School in Uganda.

In Botswana, with the world's highest infection rate, pill counts on 400 of the 10 000 patients on therapy showed that 85% were taking their pills flawlessly.

There were, however, problems with some African programmes.

The Times said that in Nigeria, Africa's most populous country, an ambitious, widely praised plan to get generic drugs to 15 000 citizens has been hampered by red tape, corruption and a scarcity of laboratories.

The newspaper also quoted a recent Cape Town study, at a Doctors Without Borders project in Khayelitsha, that found that older patients, patients who took pills twice a day instead of three times, and patients who spoke the same language as clinic staff tended to do best.

Because the drugs were scarce, the charity set high hurdles for patients, so high that only 550 of the clinic's 5 000 visitors were now taking medication. It reported extraordinarily high levels of compliance. Pill counts showed that, after six months on treatment, 96% of the patients were still taking 95% of their pills.

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