July 15, 2008

Cheap AIDS Drugs Bring Uganda Hope

Once a month, Jane Nandawula walks seven miles from her home to an AIDS clinic in Kasasa, a ramshackle collection of storefronts and huts clinging to a roadside in southwestern Uganda. There, in a tidy concrete building set back from the highway, she meets friends, gets tips on hygiene, learns about a healthy diet, and picks up her monthly dose of anti-retroviral [ARV] drugs , which help keep her HIV in check. "I was getting sick over and over -- fever, coughing, colds," says the mother of five. "But since I've started coming here and getting treatment, I feel much better."

The price she pays for her treatment: Nothing. She's one of the lucky ones, though. More than 2.4 million Ugandans are HIV-positive, and virtually every family in Uganda has lost someone to the AIDS virus. While more than 250,000 Ugandans are taking ARVs, at least 100,000 more need the drugs and aren't getting them. And only a fraction of Ugandans with HIV get free drugs or have access to the kind of care that Nandawula does.

The drugs, at least, may soon be much more readily available. In late August, a new $32 million pharmaceutical factory owned by India's Cipla and a local group called Quality Chemicals [Cipla's local distributor] is expected to start commercial production of ARVs and a treatment for malaria, another big killer throughout sub-Saharan Africa [BusinessWeek, 1/2/08]. The factory will have a capacity of 6 million tablets daily when operating full-tilt, or enough to treat some 3 million patients [BusinessWeek, 5/15/08]. "The factory will go a long way toward making the drugs available to everyone who needs them," says Fred Nalugoda, a director at Rakai Health Sciences Program, which operates 17 clinics in southwestern Uganda.

Emerging Countries Exempt From Generics Rules The plant is a sign of changing global trade regulations. A World Trade Organization agreement called TRIPS [Trade-Related Aspects of Intellectual Property Rights] has beefed up enforcement of patents on drugs [BusinessWeek, 4/18/08]. That means companies in India and China can no longer churn out generics, inexpensive copies of proprietary medications that are widely used in the developing world. Until 2016, however, countries deemed to be "least developed" -- whose ranks include Uganda -- were granted an exemption. "This plant exists largely thanks to TRIPS," says Frederick Mutebi Kitaka, finance director of Quality Chemicals.

Cipla, a big producer of such generic drugs, needed a new factory site in a least developed country so it could keep selling its wares. After meeting with Ugandan President Yoweri Museveni and other local officials, Cipla decided on a site in Kampala due to the East African nation's high prevalence of HIV and malaria and its business-friendly environment.

The plant sits among fields of bananas and corn alongside one of the potholed roads that lead out of Kampala. It is a near-clone of a Cipla facility in India, and uses the latest production and packaging equipment from the U.S., Germany, Italy, and elsewhere. The meter-thick walls and insulated windows help keep out the heat and dust, and workers must pass through three air-locks before arriving in the rooms where the compounds are actually produced. "This plant follows the most advanced manufacturing practices," says finance chief Kitaka. "Still, the cost of production in Uganda is much lower" than in Europe, the U.S., or even India. With lower production costs and an exemption from patent regulations, the new plant can sell its drugs for as little as 5% the cost of imports, Kitaka says.

Raising Cash by Selling Tomatoes Cheaper drugs will mean Uganda can afford to help more people like Nandawula. Looking down at her pale yellow gomesi, a traditional dress with high shoulders, the 31-year-old says she has had no money for new clothing since her husband died of AIDS in 2005. She gets a little cash selling tomatoes in a market near her village, a settlement called Ssanje where about 50 families live. Mostly, though, she and her five children, aged between 3 and 13, eat the cassava and beans that they raise on their small plot of land.

Ssanje is in the region of Rakai where the virus was first identified in the early 1980s. Locals called it "Slims Disease" because victims typically lost huge amounts of weight. Some towns in the region, on trucking routes to Congo and Tanzania, saw infection rates soar as high as 40% in the 1990s as drivers passed the virus on to prostitutes and it spread in the local population.

Nandawula's children haven't yet shown any signs of HIV, but she hasn't had them tested because she has no way to bring them to the clinic. "I feel bad leaving the kids at home, but what can I do?" she says quietly.

Malaria and Diarrhea Threaten AIDS Patients Despite the difficulties of getting to the clinic, she says it has changed her life. The clinic regularly dispatches so-called "peer-smart" counselors -- HIV-positive themselves -- to the homes of most patients two times a month."We check whether they've been taking their pills, advise them on nutrition, and help them figure out a better diet," says Nandawula's counselor, James Lwanaga, who proudly sports a neat white T-shirt that says PeerSMART.

Patients also get free care kits that help them stay healthy. Each one includes a plastic jug for carrying water, a filter and disinfectant tablets to make the water drinkable, a bed net to protect from malaria-carrying mosquitoes, and 60 condoms. "In the early days of the epidemic, most AIDS patients actually died from malaria or diarrhea," says Joseph Kagaayi, a doctor who works at the clinic.

The cheaper ARVs from the Cipla factory, though, are just a start. The Rakai program, which runs the Kasasa clinic, only serves about 4,000 HIV-positive people, some 1,500 of them who now take ARVs. The program is fortunate because it receives funding from the U.S. National Institutes of Health, the Gates Foundation, and other outside sources. People in other regions of Uganda must make do with less well-organized care and must bear all or part of the $1-a-day cost of ARVs. "We really need more facilities and better training of caregivers," says Nalugoda, the Rakai program director.

Uganda, like other countries in Africa, needs all the help it can get. Some 60% of the 40 million or so people who are HIV-positive globally live in the region. Uganda made great strides in reducing AIDS infection rates in the 1990s with a campaign called ABC, or Abstain, Be Faithful, and use Condoms. Today, about 6.7% of Ugandans are HIV-positive, down from 12% in 1994. But in the past few years, infections have been creeping up again as the ABC campaign has flagged. "We have been complacent," says Sam Zaramba, who oversees Uganda's public health programs for the Ministry of Health. "ABC worked well, but in recent years we haven't emphasized prevention."