RESUMO
In 2018, WHO issued guidelines for the diagnosis, prevention, and management of HIV-related cryptococcal disease. Two strategies are recommended to reduce the high mortality associated with HIV-related cryptococcal meningitis in low-income and middle-income countries (LMICs): optimised combination therapies for confirmed meningitis cases and cryptococcal antigen screening programmes for ambulatory people living with HIV who access care. WHO's preferred therapy for the treatment of HIV-related cryptococcal meningitis in LMICs is 1 week of amphotericin B plus flucytosine, and the alternative therapy is 2 weeks of fluconazole plus flucytosine. In the ACTA trial, 1-week (short course) amphotericin B plus flucytosine resulted in a 10-week mortality of 24% (95% CI -16 to 32) and 2 weeks of fluconazole and flucytosine resulted in a 10-week mortality of 35% (95% CI -29 to 41). However, with widely used fluconazole monotherapy, mortality because of HIV-related cryptococcal meningitis is approximately 70% in many African LMIC settings. Therefore, the potential to transform the management of HIV-related cryptococcal meningitis in resource-limited settings is substantial. Sustainable access to essential medicines, including flucytosine and amphotericin B, in LMICs is paramount and the focus of this Personal View.
Assuntos
Anfotericina B/uso terapêutico , Antifúngicos/uso terapêutico , Quimioterapia Combinada/métodos , Fluconazol/uso terapêutico , Flucitosina/uso terapêutico , Infecções por HIV/mortalidade , Meningite Criptocócica/tratamento farmacológico , África/epidemiologia , Anfotericina B/agonistas , Anfotericina B/provisão & distribuição , Antifúngicos/economia , Antifúngicos/provisão & distribuição , Coinfecção , Cryptococcus neoformans/efeitos dos fármacos , Cryptococcus neoformans/patogenicidade , Países em Desenvolvimento , Gerenciamento Clínico , Esquema de Medicação , Quimioterapia Combinada/economia , Fluconazol/economia , Fluconazol/provisão & distribuição , Flucitosina/economia , Flucitosina/provisão & distribuição , Guias como Assunto , Infecções por HIV/patologia , Infecções por HIV/virologia , Humanos , Renda , Meningite Criptocócica/microbiologia , Meningite Criptocócica/mortalidade , Meningite Criptocócica/patologia , Análise de SobrevidaAssuntos
Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Anfotericina B/economia , Países em Desenvolvimento , Flucitosina/economia , Meningite Criptocócica/tratamento farmacológico , África Subsaariana , Anfotericina B/provisão & distribuição , Antifúngicos/economia , Antifúngicos/provisão & distribuição , Fluconazol/economia , Fluconazol/provisão & distribuição , Flucitosina/provisão & distribuição , Humanos , Guias de Prática Clínica como AssuntoRESUMO
A review of the partnership between Pfizer Inc. and the South African Ministry of Health to distribute free Diflucan (fluconazole) in the Diflucan Partnership Program (DPP) demonstrates that product donations may be a useful response to AIDS if they are coupled with efforts to build means of drug distribution and enhance professional healthcare capacity to treat patients. Equally important is the creation of a new set of productive working relationships between stakeholders who came to the project with different backgrounds and perspectives, as well as a frankly disparate set of objectives. A decision tree illustrates how these relationships were built into the DPP. This review concludes with a few lessons learned in providing medicines not only to South Africa, but also to the 77 other African countries now participating in the DPP. As the search for new treatments and vaccines continues, increasing access to existing medicines through targeted donations--including training and infrastructure support--is the most practical way for the health community to address the problem of ill health among the poor. In addition to a detailed analysis of the DPP, there is also a discussion of the benefits of a donation program that addresses the AIDS crises on a global scale. This review may serve as a blueprint for establishing programs that are successful in fighting AIDS and improving the lives of millions of people.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Antifúngicos/economia , Antifúngicos/provisão & distribuição , Indústria Farmacêutica/organização & administração , Fluconazol/economia , Fluconazol/provisão & distribuição , Relações Interinstitucionais , Administração em Saúde Pública , África Subsaariana , Candidíase Bucal/tratamento farmacológico , Humanos , Meningite Criptocócica/tratamento farmacológico , Afiliação Institucional , Setor Privado , Setor PúblicoAssuntos
Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Antifúngicos/provisão & distribuição , Fluconazol/provisão & distribuição , Meningite Criptocócica/tratamento farmacológico , Infecções Oportunistas Relacionadas com a AIDS/complicações , Antifúngicos/economia , Antifúngicos/uso terapêutico , Indústria Farmacêutica/economia , Fluconazol/economia , Fluconazol/uso terapêutico , Humanos , Meningite Criptocócica/complicações , África do SulRESUMO
South African treatment advocates have raised national and international issues by purchasing a generic version of fluconazole in Thailand, where it cost 50 50 times less than the South African retail price, and importing it into South Africa in defiance of patent laws. Many Africans die because they cannot afford the South African price of the patented drug. The South African government has been hostile, but the action has been supported by civil society throughout the country and abroad.
Assuntos
Antifúngicos/provisão & distribuição , Medicamentos Genéricos , Fluconazol/provisão & distribuição , Antifúngicos/economia , Antifúngicos/uso terapêutico , Candidíase/tratamento farmacológico , Custos de Medicamentos , Indústria Farmacêutica/economia , Fluconazol/economia , Fluconazol/uso terapêutico , Humanos , Cooperação Internacional , Meningite Criptocócica/tratamento farmacológico , África do SulRESUMO
Pfizer, Inc.'s fluconazole costs almost 15 times as much in South Africa, where it is patent protected, than in Thailand where it is generic. The result is that many Africans die of cryptococcal meningitis and other fungal infections because they cannot obtain the patented drug at Pfizer's price. In South Africa, a coalition of major organizations has asked Pfizer to either reduce the price to the Thailand level, or voluntarily license the patent to that the treatment could be made available.