Report from the Durban WORLD AIDS CONFERENCE
Durban, South Africa
Sunday July 9
reported by Jules Levin

Report 3

PRESIDENT MBEKI SPEAKS IN 1 HOUR

The air is thick with tension, at least for me, as Pres. Mbeki is about to speak in 1 hour at the opening ceremony for the World AIDS Conference. The ceremony is taking place in an open air soccer stadium across from the convention center from where I'm writing this in the Press Room. I think he must feel as though the world is closing in on him. He's been offered low price AZT and free nevirapine for vertical transmission. the latest CDC info released at this conference and reported today in the NY Times by L. Altman was that breast feeding reverses the gains in preventing transmission. So the problem is more complicated but Mbeki is under a lot of pressure. I think he's corrupt and just doesn't want to spend the money to address this problem. It's obscene that his government so far is refusing to accept these offers from Glaxo and Boerhinger. I've heard speculation from a South African official that Mbeki will be positive but I don't think he will. I think he will take a diplomatic position with no commitment, at best. 

Today I met a person with HIV from Senegal. He said his government will give a three drug HAART regimen to 600 people for $40 per month. The usual cost for them is $800 per month. But he said people don't have the $40 either. Below is the article appearing in today's Washington Post. Signing off for now.

Africans Fear Costs Of Free AIDS Drug German Firm's Offer Requires Infrastructure

By David Brown
Washington Post Staff Writer
Sunday, July 9, 2000; Page A18 

DURBAN, South Africa, July 8óPublic health officials greeted with optimism--and some skepticism--a German pharmaceutical firm's offer to provide poor countries free doses of an antiviral drug shown to dramatically decrease mother-to-child transmission of the AIDS virus.

The offer, made by Boehringer Ingelheim, is the first concrete outcome of a commitment made by five drug companies in May to improve AIDS care in the developing world. At the same time, however, the announcement was overshadowed by twin worries that many countries may not be in a position to accept the donations, and that even if they do, the benefit may not be as great as expected.

"What it does is remove a not-insignificant obstacle--and a very big excuse--which has been used for not doing anything about mother-to-child transmission," Peter Piot, head of UNAIDS, the joint U.N. program on AIDS, said of Boehringer's offer to provide the drug nevirapine for five years. "It's not just symbolic. . . . It's quite an effort."

Piot's comment came the day before the opening of the 13th International AIDS Conference, which will be held in this port city. Durban is the largest city in KwaZulu-Natal, whose population of 7.7 million people is believed to have the highest prevalence of human immunodeficiency virus (HIV) infection of South Africa's nine provinces. In some public prenatal clinics, one-third of pregnant women are infected, compared with about one-fifth in clinics countrywide.

"One would not envision a sudden implementation," Zweli Mkhize, the province's chief public health officer, said of the offer. "That has huge financial implications. . . . The cost of counseling and testing [pregnant women] is more than the cost of the medicine."

South African Health Minister Manto Tshabalala-Msimang said on national television that she was somewhat suspicious of the timing and method of the announcement, made Friday at Boehringer's German headquarters.

"What's very strange is that we met with them last Friday and they did not [for] even one minute indicate they were going to make such an announcement," she said.

Tshabalala-Msimang's department has refused to supply the antiviral drug AZT, which also can be used to reduce transmission of the virus from pregnant women to newborns, because she is worried about its toxicity and is not convinced of its efficacy, according to previous statements.

In April, the Medicines Control Council, which licenses drugs here, stopped a trial in which five women died while taking nevirapine in combination with another drug for prevention of mother-to-child transmission. The health minister questioned the drug's safety in a speech to South Africa's Parliament.

Nevirapine is seen as an especially promising tool in stopping perinatal infection, which is responsible for about 700,000 new cases worldwide each year. In a study in Uganda reported last year, it performed better than AZT, cutting transmission to 12 percent at eight weeks after birth. A single dose of the drug was given to the mother and a single dose to the child--a regimen far less elaborate than employing AZT or other antivirals.

The head of Boehringer's HIV-drug business, Carl Pommer, said the company expected it might provide the drug to between 600,000 and 2 million mother-child pairs a year. Even at the upper range, the total would be less than 5 percent of the firm's current annual sales of nevirapine.

At roughly $4 a dose, nevirapine is within the budget of many developing countries. However, those who might find its cost a burden are likely to be those without sufficient clinical laboratories and other medical infrastructure to make full use of the offer to get it free.

"At the present, we are not in a position to give that support," Pommer said. The search for a way to finance long-range capital and organizational improvements is one of the efforts UNAIDS will try to address with pharmaceutical companies, the World Bank and other agencies as part of the "global drug initiative" announced in May.

Mkhize, the provincial health official, noted that if antiviral drugs used for chronic treatment of HIV infection were reduced to 10 percent of their current cost, they would still be unaffordable for the 4.2 million South Africans infected with HIV. Furthermore, creating the necessary medical infrastructure would cost five times as much, he said.

At the least, the World Health Organization would have to recommend the use of nevirapine, and the country's Medicines Control Council would have to approve its use by pregnant women, before the drug company's offer could be addressed, Mkhize said.

James McIntyre, a Johannesburg obstetrician and leading South African AIDS researcher, said his country is well-suited for such an intervention in that about 90 percent of women have at least one prenatal visit--at which they could presumably be offered HIV testing. However, 

only 50 percent deliver their infants in a hospital setting, which would make actual delivery of the drug difficult.

An equally vexing problem is the suggestion of some new research that many of the infants saved from infection at birth ultimately acquire it through breast milk. A study of an AZT-based regimen found that at one year after delivery, there was no significant difference in infection rates between treated and untreated African children. That finding was mentioned in a pre-conference symposium earlier in the week and reported today in the New York Times. AIDS experts questioned here were unsure what to make of the report and are awaiting details that will be provided later this week.

In a separate presentation here today, Helene Gayle, head of AIDS programs for the U.S. Centers for Disease Control and Prevention, said that AIDS cases and AIDS deaths in the United States continue to remain level, as they have for more than a year. There are about 40,000 new AIDS cases a year, down from a peak of 70,000. AIDS deaths number about 18,000 a year, down from 50,000 in 1995.

Not all states report new HIV infections--as opposed to new cases of AIDS, which is the advanced state of the disease that occurs much later. Consequently, it is difficult to determine the trend in the rate of new infections nationwide. Nevertheless, she said there are ominous data.

Last week, the San Francisco Department of Public Health said that after six years of stable HIV incidence, the rate of new cases had risen significantly between 1997 and 1999. Most new infections were in young gay men, Gayle said.