Antiretroviral treatment in developing countries: the peril of neglecting private providers

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Abstract
Dangers of unregulated prescribing Although recent reductions in the price of these drugs are welcome, the rapid increase in legal distribution will inevitably increase illegal leakage into the private sector. Evidence of uncontrolled use is already emerging in the formal and, more worryingly, informal private sector. A study from Zimbabwe in 2000 reported that a quarter of 68 private physicians were prescribing antiretroviral drugs and a quarter of 80 pharmacies were dispensing them to patients, although insurance companies did not reimburse for their use.6 The authors described prescribing practices as “therapeutic anarchy,” with prescribers and dispensers using “any ARV that they could lay their hands on.”6 Monotherapy, stocked by 82% of pharmacies, was prescribed to 17% of patients; and most of the 92 patients interviewed believed that antiretroviral drugs cured HIV infection.6 A survey of 21 Ugandan private medical facilities reported that only four of 17 facilities prescribing antiretroviral drugs had received CD4 and viral load results in the previous two months-for 38 of the 340 patients they were monitoring.7 Tests cost $150-$165 (£100-£110) per sample. Providers had to change patients' treatments because of differences in drug costs and running out of stock. Alternative sources of antiretroviral drugs were “mainly drug donations from relatives abroad and local pharmacies.”7 Of 200 HIV positive patients referred to specialist centres in India because of poor response to antiretroviral treatment, only 10% had adhered to treatment; 50% had stopped taking the drugs on the advice of traditional healers, and 80% had been receiving incorrect doses.8 In India, 60-85% of primary care provision occurs in the largely unregulated, formal and informal private sector.5 In Senegal, nine antiretroviral drugs were available in the informal private sector by 2002, all donations from northern countries that were sold on.9 The study reported monotherapy, dual therapy, and intermittent treatment, stating that “the patient demand is still very weak, but several sellers in the informal market confirm that they are about to develop marketing strategies to encourage their sale.”9 Policy makers cannot afford to await conclusive evidence that private providers will soon be at the fore-front of providing antiretroviral drugs in developing countries and that their treatment practices will accelerate HIV resistance to these drugs. Private providers are recognised to dominate the market in the treatment of sexually transmitted diseases.3 However, international and national policy makers have not acted on the available evidence.10