Thai Government Scales Up Antiretroviral Treatment Efforts
October 2003—The Thai government has launched a massive campaign to scale up antiretroviral treatment for people living with HIV/AIDS, with the ultimate goal of providing affordable drugs to all citizens who need them. An intermediate target is the provision of treatment to 60,000 Thais by the end of 2003.
A new generic antiretroviral medicine known as GPO-vir will be of central importance in the scale-up. This product, manufactured by Thailand’s state-run Government Pharmaceutical Organization (GPO), combines three previously developed antiretrovirals into a single pill taken twice daily (see the special GPO-vir section below this article).
GPO-vir, which costs about US$27 per month, will serve as the standard first-line regimen for treatment-naïve patients. The Thai Ministry of Public Health (MOPH) plans to distribute the drug via a large number of hospitals throughout the country. Some of the expenses associated with the scale-up, such as equipment to monitor CD4 counts, will be covered in part by a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria.
“Clearly, it’s good to have cheap drugs available, but the challenge is how to have enough well-trained doctors to deliver the treatment,” said Dr. Kiat Ruxrungtham, a physician at Bangkok’s Chulalongkorn Hospital and deputy director of the HIV Netherlands Australia Thailand Research Collaboration. If prescribing outpaces training in Thailand, then patients are more likely to experience problems with both drug resistance and side effects. Ruxrungtham noted that nevirapine, one of the components of GPO-vir, has certain side effects that, while uncommon, are potentially life threatening.
The Thai MOPH and its allies in the scale-up recognize that GPO-vir does not provide a solution for everyone in need of treatment. It is anticipated that patients who have received dual-combination therapy earlier may be resistant to one or more of the antiretrovirals that comprise GPO-vir, and that 10 to 15 percent of antiretroviral-naïve patients given GPO-vir will experience side effects that force them to switch to a different regimen.
While the challenges for physicians and people with HIV/AIDS are significant, there are signs that Thailand is ready for this undertaking. Ruxrungtham, who is also secretary of the Thai AIDS Society, noted that health care providers have shown growing interest in HIV treatment now that effective regimens are more available. More than half of the participants at the Thai AIDS Society’s most recent training were “new faces,” he said. “Doctors are enthusiastic—I think that’s a really good sign.”
The MOPH has been commended by some observers for its commitment to involving nongovernmental organizations (NGOs) and people with HIV/AIDS in the scale-up. “I think the government realizes that it can’t do this alone,” said Paul Cawthorne, head of the Thai mission run by Médecins Sans Frontières (MSF) whose organization has worked closely with the MOPH on logistical issues. MSF is training people with HIV/AIDS to promote medication adherence and to provide other forms of support to patients eligible for treatment.
Cawthorne advocated for a spirit of cooperation among the many parties involved in this massive undertaking. “Of course there will be problems,” he said. “Some hospitals are going to manage the implementation better than others. But overall, this is a huge step forward. I think we all need to work together instead of finger-pointing.”
Nimit Tienudom, director of Thailand’s AIDS Access Foundation, reported that his group is working to help the government create training curricula for health care providers. The AIDS Access Foundation is also promoting community education and peer support. People taking antiretroviral therapy, Tienudon stressed, need to have a good understanding of issues such as the importance of compliance and the danger of side effects.
The Thai government has a long history of allocating part of its limited resources to treatment. Government-subsidized antiretroviral therapy was introduced on a small scale between 1992 and 1995, but with single and dual-combination therapy regimens. Thai health officials declared highly active antiretroviral therapy (HAART) to be the national standard of care in 2000; the cost of the regimens, however, remained a major obstacle to the government and to most people.
GPO-vir: Cornerstone of Scale-Up Strategy
The Thai government’s effort to scale up antiretroviral treatment has been greatly facilitated by the introduction of a generic product named GPO-vir. The Government Pharma-ceutical Organization (GPO), a division of the Thai Ministry of Public Health, designed GPO-vir in order to incorporate three antiretrovirals into a single tablet. GPO-vir contains stavudine (d4T), lamivudine (3TC) and nevirapine, which together form a suitable highly active antiretroviral therapy (HAART) regimen for many patients in need of treatment.
GPO-vir’s twice-daily dosage schedule makes it one of the easiest regimens for people to take. At approximately US $27 per month, it appears to be one of the cheapest HAART regimens in the world. (An Indian drug company, Cipla, combines the same three drugs into a single pill, triomune, which is in the same price range.)
According to Achara Eksaengsri of the GPO’s research and development institute, affordability and convenience of administration were both goals that guided the development of GPO-vir. By combining a full regimen into one twice-daily tablet, Eksaengsri explained, the GPO hopes to promote high adherence rates, which will reduce the likelihood of drug resistance.