Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

830 Abstracts 42254-42286

12th World AIDS Conference

the US during 1997. Respondents who knew their diagnosis for >3 months or
ever received antiretroviral therapy were included.
Results: Of 1,204 patients completing an interview, 985 (77%) were currently
taking antiretroviral therapies. Of these, 918 (93%) were taking 2 or more antiretroviral agents; 621 (63%) were taking one or more protease inhibitors. Women
(42% vs. 55% for men, p < 0.01), blacks (42% vs. 62% for whites, p < 0.01),
persons <35 years old (47% vs. 54% for 35+, p < 0.05), injecting drug users (46%
vs. 60% for gay men, p < 0.01), HIV+, non-AIDS (35% vs. 54% for AIDS patients,
p < 0.01), CD4 counts >500 (40% vs. 56% for <500, p < 0.05), facility-based
site (45% vs. 63% for population-based, p < 0.01) uninsured (41% vs. 57%
for insured, p < 0.01), those with annual incomes <$10,000 (47% vs. 61% for
>$10,000, p < 0.01), and unemployed (49% vs. 59% for employed, p < 0.01)
were less likely to be taking protease inhibitors. Logistic regression analysis of
these factors showed that respondents who were not on protease inhibitors were
more likely to be black (adjusted odds ratio [AOR] 2.5, 95% confidence interval
[Cl] 1.6-3.9), AIDS patients (AOR 2.2, Cl 1.5-3.2), and have incomes <$10,000
(AOR 1.6, CI 1.2-2.0).
Conclusions: More than three fourths of HIV infected patients are currently
receiving combination antiretroviral therapy. However, protease inhibitors may
be less accessible to persons of low socioeconomic means. Continuing efforts
are needed to ensure that highly effective antiretroviral therapies are equally
accessible to all infected persons.
444*/42283 One world, one hope: The cost of making
antiretroviral therapy available to all nations
Robert Hogg, K.J.P. Craib, A. Weber, A. Anis, M.T. Schechter, J.S.G. Montaner,
M.V. O'Shaughnessy. BC Centre for Excellence in HIV/AIDS, 608-1081 Burrard
St., Vancouver, BC, Canada
Objective: To estimate the potential economic cost of making triple combination
antiretroviral (ARV) therapy widely available to HIV-positive adults living in 155
countries throughout the world.
Methods: For each country, ARV costs were obtained by multiplying the average annual cost of triple ARV therapy by the estimated number of HIV+ adults
on ARV treatment. These figures were derived from a population-based program
where triple ARV therapies are provided free of charge in a manner consistent
with current therapeutic guidelines (Carpenter, 1997). Per capita ARV costs were
then computed by dividing the ARV costs by the country's total population. The
potential economic burden was calculated by dividing per capita ARV costs by the
GNP. Estimates of population of HIV+ persons, GNP, and other national health
indicators (clean water availability, years of school, urban population size, life
expectancy, use of modern contraception) were taken from UN, WHO, and World
Bank figures for 94-95. All figures are in 1997 US$.
Results: The estimated annual worldwide cost of triple ARV therapy was 36.5
billion US dollars of which 66% would be spent in Africa. The per capita cost was
$6 or 0.13% of GNP worldwide. Per capita costs was highest in sub-Saharan
Africa at $41 or 8.3% of GNP and lowest in Europe and Oceania at $1 or 0.01%
of GNP. In Asia, the per capita cost was $2 or 0.04% of GNP and in the Americas
it was $6 or 0.13% of GNP. ARV costs would exceed 50% of the GNP in Malawi
(84%), Mozambique (67%), Uganda (61%), and Tanzania (51%). In a multivariate
log linear regression analysis of data from 155 countries, ARV cost as a proportion
of per capita GNP was independently and inversely associated with the country's
life expectancy (r = 0.73) and % of the population living in urban centers (r = 0.62).
These two variables explained 55% of the variation in the dependent variable.
Conclusion: Our results demonstrate that the cost of making triple combination
anti-HIV therapy available worldwide will be exceedingly high, especially in Africa.
Furthermore, before ARV access can be widely adopted, countries will require
substantial improvements to their health infrastructure and distribution systems.
Overall we believe recent initiatives to facilitate access to HIV treatments, like the
one announced by the Joint United Nations Programs on HIV/AIDS (UNAIDS) in
collaboration with the pharmaceutical industry, need to be greatly expanded to
the regions and countries with the greatest need.

users (IDUs) and 14.4% are women. Among MSM, the distribution of antiretroviral
use is: 81% of Stage IV, 76% of Stage III and 58% of Stages I & II. IDUs, the
distribution of antiretroviral use is: 38% of Stage IV, 34% of Stage III and 33%
of Stages I & II. Finally, for women in the study, the distribution of Antiretroviral
use is: 47% of Stage IV, 38% of Stage III and 29% of Stages I & II. With respect
to antiretroviral use, the populations of IDUs and women are statistically different
from MSM. The reported median time that respondents in these groups believed
they were infected was 9 years for MSM, 5 years for IDUs and 3 years for women.
Conclusion: The relatively low use of Antiretroviral therapy by two emerging
populations (IDUs and women) at risk for HIV presents concerns for effective
provision of antiretroviral therapies. In British Columbia, antiretroviral drugs are
available at no charge to residents of the province. The disparity in Antiretroviral
use controlling for disease staging indicates the need for investigating the underlying causes. These results also suggests that the potential for Antiretroviral
therapy to contribute to primary prevention of HIV transmission is limited among
these populations.
500*/42285 Barriers to HIV antiretroviral therapy among
injection drug users in settings with and without
universal health insurance coverage
David Celentano, R.S. Hogg, D. Vlahov, S.A. Strathdee, R.D. Moore, A. Palepu,
S. Cohn. Johns Hopkins University 615 N. Wolfe St. (E-7132) Baltimore, MD,
USA; BC Centre for Excellence in HIV/AIDS, Vancouver, Canada
Objectives: To compare HIV antiretroviral therapy (ART) among IDUs in a universal health care setting (Vancouver -Vcv), including free ART, and an individual
insurance system (Baltimore - Bait).
Design: In Vcv, record linkage between survey data and a provincial HIV/AIDS
treatment registry over the period July 1996 through August 1997; in Bait., through
self-reports of ART between July 1996 (IAS guidelines released) to June 1997.
Methods: 171 Vcv active IDUs with CD4 counts <500 mm3 were recruited from
May 1996 into a cohort study, and use of ART from the provincial registry. Their
physician HIV experience was determined by the cumulative roster of HIV-infected
patients receiving ART. In Bait, 404 HIV-infected IDUs with CD4 counts <500
mm3 recruited in 1988-89 were interviewed about ART over one year beginning
in July 1996. Utilization of health services and ART were then compared.
Results: After 11 months of eligibility, 40% of Vcv residents had received any
ART, mostly double combinations (67%). After 12 months in Bait, 49% of patients
were on ART, but only 14% received a protease inhibitor. In Vcv, IDUs accessing
physicians with low HIV experience were 5X less likely to receive ART. In Bait,
unstable living conditions and isolation from the medical care system were associated with not receiving ART. In Vcv female IDUs were 2X less likely to receive
ART but not in Bait. In both cities, continuing drug use was associated with not
receiving ART.
Conclusion: Injection drug users are unlikely to be receiving ART recommended by the IAS. Despite free access to HIV ART in Vcv, in which all citizens
are covered by universal health care, barriers to utilization and optimal therapy for IDUs persist. Provider inexperience and concerns about adherence and
development of resistance requires immediate educational efforts to improve
treatment.
S42286 Malawi: Drug treatments for HIV/AIDS patients - Dream
and reality
Martin Preuss, J.B. Phiri Sam, Chikondi Msusa. Lilongwe Central Hospital PO
Box 149, Lilongwe, Malawi
Issue: 30-40% of Malawi's sexually active urban population is already HIV infected. Purchase of antiretroviral drugs (excluding logistics of distribution and
monitoring) to treat all of these patients with triple anti-retroviral therapy would
cost approximately 370% of Malawi's GNP (Lancet 1997, 350, 1406). The Malawi
Goverment allocates $2/capita/year for health care services. Given such resource
constraints we set out to investigate what drug treatments are available, and at
what cost, to HIV/AIDS patients in Malawi.
Methods: A list of 85 drugs commonly used for the management of HIV/AIDS
patients was compiled. We compared this list with the essential drugs list for
Malawi and with those drugs currently available through the (free) government
health service through the Central Medical Stores and central hospital pharmacy.
In addition we investigated drugs that could be purchased through three private
pharmacies in the capital city.
Results: 1. Antiretroviral therapy. No antiretroviral drugs are included in Malawi's
Essential Drug List. They are not available at any level of the public health service.
Two antiretroviral drugs could be purchased at one of the private pharmacies. An
average Malawian worker's monthly salary would be consumed by only 2 days of
treatment with these drugs. 2. Prophylaxis. Co-trimoxazole is currently available
through the public health sector without cost to the patient and thus PCP/toxo
prophylaxis is theoretically possible. 3. Anti-fungal treatments. Treatment of HIVassociated fungal infections is difficult in Malawi as anti-fungal drugs are indexed
as essential but are unavailable through the public health service. The drugs are

available in the private pharmacies, but exceed the economic capability of most
patients. 4. TB treatment. First line anti-TB drugs are reliably available through the
donor-funded National Tuberculosis Control Programme at no cost to the patient.
Conclusions: The international community must face the reality of gross
treatment inequalities in HIV/AIDS care. For Malawian HIV/AIDS patients is that
recommended treatment of their disease can only be a dream. International policy
has to change.

142284

Variations in antiretroviral drug use between groups of
persons living with HIV controlled for disease staging in
Vancouver, Canada

Robin Hanvelt, D.G. Schneider, T.T. Copley, N.L. Meagher. BC Centre for
Excellence in HIV/AIDS at St. Paul's Hospital 613-1081 Burrard Street,
Vancouver, BC V6Z1Y6, Canada
Objective: To compare the use of Antiretroviral therapy for different risk groups.
Design: Prospective, Convenience Sample.
Methods: 500 adults with confirmed HIV diagnosis were recruited from clinical
and community access points into a longitudinal survey for studying the economic
cost and resource impacts of HIV in British Columbia. Survey participants were
enrolled in the study from August 1996 to July 1997 and are interviewed at 3
month intervals over a 15 month period. The following analysis is based on the
baseline interview data.
Results: The sample was stratified for disease progression based on modified
WHO staging criteria. Sufficient clinical and laboratory data was available to
stage 79% of the sample population. Of the staged population 53% reported
Antiretroviral use while 17% of the population that could not be staged were using
Antiretroviral drug therapy. The following Antiretroviral use profiles for the staged
population include three groups of interest: 34.3% are men who report sex with
men as the likely cause of HIV transmission (MSM), 44.8% are injection drug