The data presented here derive from the authors' involvement in efforts to expand access to antiretroviral drugs in Burkina since 1995, as well as interviews conducted in December 2001*. Although community groups now have considerable experience with antiretroviral drugs (ARVs), little has been published to date .
Evolution of availability of antiretroviral drugs in Burkina Faso
The advent of highly active antiretroviral therapy (HAART), and the ensuing therapeutic optimism that culminated at the XIth International AIDS Conference in Vancouver in 1996, focused attention on access to antiretroviral treatment for Africans living with HIV. At that time, the number of Burkinabè who had been tested for HIV, found to be positive, and informed, were few, but there were a sufficient number to constitute a market for these drugs. The first ARVs available for purchase in private pharmacies were brand-name zidovudine, didanosine, stavudine and indinavir, which were found in local private pharmacies from 1996, although the high cost of these drugs was a significant barrier to their proper use. Nonetheless, many use their savings and mobilized resources to purchase limited quantities of ARVs for personal use. This led to irrational use of the drugs, with most patients only able to afford intermittent monotherapy or, at best, dual therapy. A study conducted in 1998 also found that a number of practitioners were prescribing and administering antiretroviral ‘cocktails’ in dosages that were of unproven benefit and unlikely to be effective – for instance, monthly treatments cycling zidovudine, ciprofloxacin and gancyclovir were reported . This shows that ‘antiretroviral anarchy’  occurs in the absence of programmes to expand and rationalize, access to treatment.
In 1999, the Burkinabè government moved to regulate procurement of ARVs by simultaneously licensing these drugs and limiting authorization to import the drugs to the CAMEG, a para-statal company that procures, distributes and promotes essential generic medicines at cost. However, little was done to rationalize their use. The CAMEG began importing ARVs in April 1999, in the process halving the price of triple therapy, which went from an average 600 000 CFA (roughly US$ 800) per month of treatment to 300 000 CFA (roughly US$ 400). Within a month, pledges were made by pharmaceuticals manufacturers to reduce the prices of ARVs, largely as a result of international lobbying on the part of AIDS activist groups. When this political pressure was joined by competition from generic ARVs manufactured in India and elsewhere, the prices of ARVs dropped much more significantly . As a result, the cost per month of the cheapest triple therapy has dropped from over 600 000 CFA per month at the end of 1998 (US$ 798) to 77 125 CFA (US$ 103) in June 2001 and prices have held at that level since.
How individuals obtain antiretroviral drugs
For ARVs the CAMEG exceptionally sells directly to individuals who have a prescription from a physician who has been approved to prescribe these drugs. In the first year that it sold ARVs to individuals, the CAMEG furnished treatment to 135 patients. The subsequent decrease in price is cited as the principal reason for the increased uptake of ARVs: in 2000, the year of the price reductions, CAMEG supplied 165 patients. This increased to 528 in 2001, and currently the number of patients purchasing ARVs through the CAMEG has increased to over 700 .
In addition to private purchase through the CAMEG, ARVs drugs are also available through drug donations managed by local organizations. These take two forms. In the first, grants are made specifically for the purchase of drugs to treat people living with HIV. This is a little-used mechanism, as the vast majority of donor agencies do not give grants for purchases of drugs, referring to their inability to commit to sustaining such funding. However this picture may be changing. In Ouagadougou, the Centre de traitement ambulatoire, (CTA) an ambulatory care centre established through a collaboration between the French Red Cross and the Burkinabè Ministry of Health, has received a grant ensuring a lifetime supply of HAART for 300 individuals.
Second, drug recycling programs furnish in-kind donations. These are collected in northern countries by health care workers and patient groups, and then sent to southern correspondents for use by patients there. A small but growing number of Burkinabè with HIV, whose membership in patient groups gives them contacts with northern activists and organizations, have access to these recycled drugs. In Burkina as elsewhere, drug recycling programs are proliferating and have been the vanguard of subsequent expanded ARV access programs [6, Tavi-Ouattara Y, personal communication, 2002].
These donations occur either on an individual-to-individual basis, as in the case of Burkinabè living abroad who collect drugs for afflicted relatives, or as group-to-group donations. Groups involved in AIDS care in France and Canada recycle unused drugs by shipping them to a number of Burkinabè non-governmental organizations (NGOs) that have established programs to care for people living with HIV. Currently, at least three local groups are able to offer some treatment support in the form of donated ARVs for an estimated 100 persons with HIV, most of whom also purchase part of their treatments using their own funds, or receive direct donations from friends and relatives abroad. Less than 20 of these are entirely dependent on drug recycling program donations for their treatment. As individuals treated through donations may occasionally purchase ARVs from the CAMEG, it is difficult to establish a total number of patients on treatment with certainty, as patients move from being able to purchase drugs to relying increasingly on donations as funds dry up, to being able to move back to purchasing drugs again if the prices drop.
One community-based experience with donated drugs
One grassroots community group in Ouagadougou, the Association African Solidarité, has stocked recycled drugs for the last 3 years. Cost was not used to ration the drugs. Rather, informal criteria were employed to use the drugs as effectively as possible given their limited supply. In the first 2 years of use, the drugs were mostly used to tide over patients who were already paying for treatment and who otherwise might have had to interrupt their treatments, either because drugs were unavailable for purchase or they did not have enough funds. In addition, some very ill patients were treated ‘on humanitarian grounds’.
The outcomes of the first 50 patients treated in this manner between June 1998 and August 2000 were examined in a review of the organization's records. Twenty-eight patients were able to afford CD4 cell counts, and the average CD4 cell count was 146 × 106 cells/l (median 89 × 106 cells/l). Three were treated with monotherapy, 34 with double nucleoside reverse transcriptase inhibitors (NRTI) therapy, two with double NRTI therapy plus hydroxyurea, and 11 with triple therapy. During this period, 15 patients died, 20 did not return regularly for follow-up and 15 are still followed regularly. Most of those who did not return for regular follow-up withdrew because they could no longer afford to pay for drugs and there was an insufficient stock of recycled drugs to keep them on treatment. In other words, while they had been offered recycled drugs as a temporary measure with the understanding that they would be able to resume paying for their treatments, this did not turn out to be the case. Having exhausted their personal finances and/or their ability to mobilize resources from family members and friends, most of these patients were unable to resume purchasing ARVs and, as a result, did not return for follow-up.
Observations and lessons learned
Four observations from the Burkinabè experience with ARVs merit consideration. First, cost has been, and remains, the main barrier to increased access and adherence to treatment. This mirrors experience in other African countries . Second, as prices have gone down, access has increased and some infrastructure has followed, largely in the form of community organizations' attempting to respond to the needs of people living with HIV. Further investments in infrastructure and, more importantly, human resources to support optimal adherence are urgently needed. Third, NGOs have been the most responsive to the need to expand access to treatment. However, and this is our fourth observation, the dynamism of the community response resulted in synergies with the public health care system. For instance, institutions such as CAMEG can help decrease costs through rationalized procurement, thereby increasing access, and new models of NGO-type governance can be experimented with within the public health care system, as in the case of the CTA. Over the long term, we believe that these new models of community-driven health care advocacy and private–public synergies will, if given adequate financial support, help to change the culture of public health and increase health equity in countries like Burkina Faso.
This experience parallels that of other groups in Africa that have had access to ARVs. Most of these groups had not thought out beforehand how to use recycled drugs, but used informal criteria to make the best use of them. These criteria have at times conflicted with western donors' priorities for treatment. Donor agencies may prefer to target the groups they perceive to be most vulnerable (women and children, for instance) with an eye to reducing inequities in health care access. However, treating certain categories preferentially may undermine solidarities within groups or lead to perverse effects, such as patients sharing their drugs with those who do not have access to treatments. Relying on ‘objective’ medical criteria, such as CD4 cell counts, may also be inequitable. The poor, for instance, access health care later and often present with significant comorbidity that may label them as being at a higher risk for treatment failure, either because of ‘non-adherence’ or rapidity of disease progression. Alternatively, clinical criteria that are too broad allow social biases to creep into decision-making concerning who should have access .
Despite expanded access to ARVs in Africa, rationing will always be a reality, posing a challenge for health equity. Although all agree that equity is the goal, strategies for achieving equity may differ. This experience shows that local groups may chose to ration access differently than donor organizations. It will be important to establish a process that respects local views with how to use ARVs most effectively and equitably, as well as establishing selection criteria that are clear, identify those who need treatment most urgently, and are transparent and accountable to local decision-making processes.
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