Médecins Sans Frontières


In Thailand, patient activism is crucial to expanding treatment

In December 1999, over 300 people with HIV/AIDS demonstrated outside the Public Health Ministry for three days, in support of a request by GPO for a compulsory license to allow it to make generic versions of the ARV didanosine (ddI). It was the first time in Thailand that HIV positive people had braved stigmatisation to stage public demonstrations and it proved to be a watershed event.

By David Wilson and Nathan Ford

These political efforts to promote access to generic medicines went hand in hand with efforts to ensure that, as the cost of treatment decreased, availability increased.

Access to antiretrovirals in Thailand has increased eight-fold in the last three years, with 50,000 people due to receive treatment by the end of this year. People living with HIV/AIDS have been the crucial actors.

There are currently more than 700 groups of people with HIV/AIDS in Thailand, mostly hospital-based and government-funded, co-ordinated by TNP+, the Thai Network for People Living with HIV/AIDS. Particularly crucial has been their support for the production of generic antiretrovirals (ARVs) by the Government Pharmaceutical Organisation.

In December 1999, over 300 people with HIV/AIDS demonstrated outside the Public Health Ministry for three days, in support of a request by GPO for a compulsory license to allow it to make generic versions of the ARV didanosine (ddI). It was the first time in Thailand that HIV positive people had braved stigmatisation to stage public demonstrations and it proved to be a watershed event.

When the application for a compulsory licence was rejected by the Thai government for fear of US trade retaliation, patient groups then led a challenge on the didanosine patent itself, filing a lawsuit against its patent-holder Bristol-Myers Squibb in May 2001.

Their challenge was successful: after a year and a half, the Central Intellectual Property and International Trade Court set an important precedent ruling that, because pharmaceutical patents can lead to high prices and limit access to medicines, patients are injured by them and can challenge their legality.

These political efforts to promote access to generic medicines went hand in hand with efforts to ensure that, as the cost of treatment decreased, availability increased.

In order to distribute ARVs throughout the country, TNP+, AIDS Access Foundation and MSF set up a Buyers' Club in October 2000. Medicines are made available within a supportive environment -- doctors write a prescription, which the patient takes to their patient group, which dispenses the medicines together with appropriate treatment information, counselling and assistance in planning dosage schedules.

At its peak in June 2002, 21 Buyers' Club branches across the country enabled 1081 people with HIV/AIDS to access treatment. Since then, more patients have gained access to treatment through Ministry of Public Health programmes.

This mixture of practical and political support for access to treatment, with patients and health care providers working together on an equal basis, has built firm foundations for the rolling out of antiretrovirals across the country.



Médecins Sans Frontières

Advances in Thailand often due to AIDS activism

A debate confined to issues of cost-effectiveness is too narrow, and polarisation of the debate into a prevention versus HAART argument will not help either cause.

This letter first appeared in the July 6 edition of The Lancet

Provision antiretroviral therapy in resource-poor settings needs concerted dialogue with health workers and patient groups. Activism needs to respond to legitimate concerns.

Sir - Elliot Marseille and colleagues believe that activism for access to AIDS treatment prevents informed debate about resource allocation.

In Thailand, activism has a more positive outcome. The yearly budget of the Thai government for antiretrovirals has been constant since 1995. Attempts in 1998 to reduce the price of these drugs by producing them locally met with aggressive pressure by the US government and the pharmaceutical industry.

Activist support drew attention to the right of Thailand to produce generic antiretrovirals.3 Six generic antretrovirals are now available, with one triple regimen costing US$27 per month per patient. A demonstration on World AIDS Day, 2001, by more than 1,000 Thai people with HIV/AIDS in front of government house, demanded that the government increase access further by including antiretroviral treatment in a new universal health insurance scheme. A joint Ministry of Public Health/Non-governmental organisations committee was then established to scale up implementation of AIDS treatment.

Informed debate is necessary during implementation of treatment programmes and during the process of resource allocation.

Médecins sans Frontières (MSF) supports three district hospitals setting up antiretroviral treatment programmes in Thailand. Preliminary training sessions gave us the chance to assess the motivation and concerns of the hospital staff.

Most staff commit themselves to working in these difficult programmes mainly to prevent new infections. They share Marseille and colleagues' scepticism that HAART makes prevention more effective and they worry that making treatment widely available could encourage high-risk behaviour. Such concerns need to be discussed openly and all opinions respected. Nevertheless, staff in all three hospitals also want to work for the good of the whole community and feel they cannot do a complete job without providing treatment.

Not providing treatment leads to a sense of hopelessness in both staff and patients, which reduces the effectiveness of prevention interventions.

Provision antiretroviral therapy in resource-poor settings needs concerted dialogue with health workers and patient groups. Activism needs to respond to legitimate concerns. However, a debate confined to issues of cost-effectiveness is too narrow, and polarisation of the debate into a prevention versus HAART argument will not help either cause.

Most importantly, a massive increase in funding assistance from western governments is needed. The Global Fund for AIDS, tuberculosis and malaria, standing at a tenth of what is required to fight AIDS alone, is a tragic indictment of the inadequate worldwide commitment to the world's greatest pandemic.

Médecins Sans Frontières (Belgium) in Thailand receives funding from the European Union.

By David Wilson

Médecins Sans Frontières, 311 Ladphrao Soi 101, Bangkok 10240, Thailand (e-mail:msfbthai@ksc.th.com)

Footnotes:
1 Marseille E, Hofmann P, Kahn J. HIV prevention before HAART in sub - Saharan Africa. Lancet 2002; 359: 1851 - 56 [Text]
2 Wilson D, Cawthorne P, Ford N, Aongsonwang S. Global trade and access to medicines: AIDS treatments in Thailand. Lancet 1999; 354: 1893 - 95 [Text]
3 von Schoen Angerer T, Wilson D, Ford N, Kasper T. Access and activism: the ethics of providing antiretroviral therapy in developing countries. AIDS 2001; 15 :(suppl) S81 - S90




 


use back button on browser to return



back to Bangkok AIDS Conference index