ANGOLA – LUANDA (PlusNews) - Every month, Carolina Pinto has to rely on friends in another continent to collect, send on and deliver her lifesaving antiretroviral drugs (ARVs) to Angola’s capital Luanda.

One person picks up the medication at a hospital in one of Brazil’s major cities, São Paulo, and sends it by mail to Bahia, on northeastern part of the country’s Atlantic coast. There, another friend passes the package on to a third person who brings it to Luanda.

This lengthy process began after Pinto became resistant to the ARVs she had been prescribed and required what are known as ‘second-line drugs’, which are currently not available in Angola.

Pinto is an activist with the non-governmental organisation Luta pela Vida (Fight for Life in Portuguese). When she began taking antiretrovirals in 2001, she had to travel from Angola to Pretoria in South Africa to collect them.

At the time, Brazil and South Africa were the only options for HIV-positive Angolans. For those without the resources, it was a lottery: the Medical Commission in Luanda decided who they would fund to make the regular costly trips.

Carolina Pinto was one of the chosen ones. But she wasn't always able to secure her ticket before the three-month supply she received in Pretoria ran out. It was these interruptions in treatment that caused her to develop a resistance to one of the drugs in 2005.

Now, Pinto lives in fear that her monthly package from Brazil will be delayed and her treatment interrupted again.

"It is agonising," said António Ribeir, the coordinator of the National Network of Persons Living with HIV and AIDS. "Many HIV patients go from country to country to get their medication." (See insert)

Such complex logistics may soon be unnecessary. According to Ducelina Serrano, director of the National Institute for the Fight Against AIDS (known by the Portuguese acronym INLS), the government body responsible for Angola's AIDS programmes, enough second-line medication for 1,500 adults and 200 children was due to arrive in the country by the end of October.

Determining when to switch patients from first to second-line drugs presents another challenge. António Feijó, the director of Esperança (literally, 'Hope', in Portuguese) Hospital, a referral facility for HIV patients in Luanda, explained that the tests necessary to determine drug resistance are not yet available throughout Angola's public health network.

...there are cases in which we think that the drugs aren't working when actually the treatment isn't being carried out correctly.

Serrano said viral load equipment would be installed in the Institute's molecular biology laboratory by the end of 2007. However, there is currently no data regarding the levels of first-line ARV drug resistance in Angola, which has 16 million inhabitants and an average HIV prevalence of 2.5 percent. A two-year survey currently being carried out by the INLS, the Spanish Cooperation Agency and the UN World Health Organization should help to fill this gap.

According to Feijó, poor adherence to treatment programmes is another factor contributing to drug resistance. "Many HIV patients don't take their medication on weekends because they want to drink. Others, who hide the fact that they take the medication, halt the therapy when their partners are at home. So there are cases in which we think the drugs aren't working when actually the treatment isn't being carried out correctly," he explained.

Over time, Feijó added, most patients develop some type of resistance to one or more of the ARV drugs.

"In general, this takes place after between four and six years of therapy, but of course this depends on each individual and on adherence to the treatment regimen," he said.
Although it has been hailed as a breakthrough, the imminent arrival of second-line drugs in Angola has caused concern among medical experts.

"This treatment has more side-effects and requires patients to follow a strict treatment schedule and diet," said Feijó.

Serrano agreed: "Our concern is to avoid a public health problem, given that if people don't adhere to the treatment programme, it could create generalised resistance."

Roberto Campos, an official at UNAIDS, warned that the responsibility for sticking with the treatment does not belong to the patient alone.

"The key to the continuity of therapy is a quality health service, with the constant presence of the doctor and universal access to antiretrovirals. It is also important to create self-help groups to encourage HIV patients to follow ARV therapy," he said.

According to Ribeiro, support groups have already been set up in several provinces.

New targets

In June 2007, 8,834 adults and 429 children were accessing ARV therapy in Angola.

By 2008, the INLS hopes to triple this figure to 25,000 people, and the government plans to increase the AIDS response budget from US$38 million to 45 million.

But with an increased demand for second-line drugs, which are more expensive, costs are likely to go up.

According to Campos, the solution is to negotiate with the companies that manufacture them.

"This can be done in one of two ways: either the Angolan government can negotiate directly with the pharmaceutical companies, or it can do so through the mediation of international [donor] organizations, such as the Bill Clinton Foundation," he said.

In May, the William J Clinton Foundation negotiated reductions of up to 50 percent on the price of second-line ARVs, which generally cost ten times more than their first-line counterparts.

Carolina Pinto may soon travel to the airport to welcome her friends, not just her medication.