Belinda Beresford
The doctor, staring into the bottom of his coffee mug, had watched a man and a woman decide who was going to die first. In their early 30s and with young children, they have less than a tenth of a healthy person’s immune system between them. From their joint income a disability pension and occasional work they could squeeze R600 a month for basic anti-retroviral therapy. This could help the immune system of one of them to recover, so that at least one parent would be able to raise their children for a few months or even years longer.
Since the man was the sicker looking of the two, they decided that he should get the drugs. But for the doctor there were three problems. The first was that it was the wife who was about to die. Very soon. Her disability pension would stop and the man would have no chance of raising R600 a month.
The second problem is that this is the theoretical price for a basic triple cocktail of anti-retroviral drugs, based on pharmaceutical company promises to sell cheap drugs to developing countries. One good first line triple therapy combination is ddI/d4T (now being offered for $1 a day by Bristol-Myers Squibb) and efavirenz. Price reductions by Merck mean that efavirenz is now about R360 a month. Add the cost of the ddI/d4T and you get good triple therapy for R600 a month. But the third problem facing the doctor is, who is going to pay for the tests needed to keep someone safely and healthily on anti-retroviral drugs? The national Department of Health says it has no policy on what to do with poor patients who use the public health service, are not medical aid members and yet who could when cheaper drugs materialise in pharmacies afford to pay for double or triple therapy.
Even the basic costs of maintaining someone on such therapy are high.
Patients need multiple tests for viral load (the number of viral copies in the blood); CD4 (a measure of the strength of the immune system), as well as liver function tests, glucose tests and full blood counts. A doctor from the clinical HIV research unit at Wits University has calculated the kind of hidden costs involved in anti-retroviral therapy, assuming the patient has no problems with the treatment. Ignoring pre-treatment costs, a patient would need a viral load test probably four or five times in the first year and a CD4 count twice. A baseline full blood count would need to be given, so the cost of approximately four visits a year to the doctor should also be added in.
If a non-nucleoside inhibitor such as efavirenz is being used, then patients need glucose and cholesterol tests probably twice yearly. If nevirapine is being used, they need at least four liver function tests in the first year, and the same number of full blood counts would be needed for patients taking AZT.
In the private sector viral load tests cost more than R800 and CD4 counts are more than R200. A full blood count is about R80, with liver function tests more than R200 each. So a patient taking ddI/d4T and efavirenz would probably be looking at private sector costs of at least R4000. Even at cheaper rates available to the state it would cost several thousand rand.
All these ballpark figures assume that no extra costs are incurred to treat the side effects that are so common with this kind of treatment. The doctor who treated the couple had also seen four other patients that day who had seen reports on drug price reductions and hoped they could afford anti-retroviral therapy.
But the lower price promises have not yet been translated into action. For example, the Bristol-Myers Squibb offer in mid-March to cut the price of the ddI/d4T combination to $1 a day only applies to four countries: Senegal, Rwanda, Uganda and Cte d’Ivoire. Bristol-Myers Squibb representative Bob Laverty said South Africa was not eligible to benefit from the offer, because the government had not yet expressed an interest in it. He was unable to say whether private sector representatives could approach the company for the same prices. Such uncertainty is cold comfort for a doctor having to face people who are racing against time and asking him for what seem to be illusionary drug prices that could save their lives. Weeks matter to people enduring full-blown Aids. And the comfort is even colder for the doctor who doesn’t know whether he’ll even be able to treat patients with the drugs when they do manage to get them or whether he’ll just watch people self-medicate.
At best they will be wasting their money, at worst damaging their health further and maybe contributing to the levels of drug resistance, which could mean HIV becomes uncontrollable. Additional reporting by Suzan Chala