- Email: [email protected]
Taking HIV to court
EDITORIAL
THE LANCET Volume 358, Number 9283
Taking HIV to court The decision on how to treat people with HIV infection has never been a simple clinical matter alone. From the beginning of this epidemic each new treatment has been scrutinised, and criticised, as never before, by scientists, doctors, and people with AIDS. The litany of accusations is long: not making new medications available quickly enough; use of drugs without adequate safety testing; drugs being too expensive; and pharmaceutical companies keeping a monopoly on the production of drugs. Increasingly, dissatisfied individuals and groups are resorting to legal action. Two cases currently underway in South Africa illustrate the extremes of opinion. The first case has been brought by a coalition of groups: the Treatment Action Campaign, an organisation that lobbies for affordable treatment for people with HIV infection; Haroon Saloojee, a paediatrician from Johannesburg on behalf of Save Our Babies—a group of paediatricians and maternal and child-health practitioners; and the Children’s Rights Centre, which represents children with HIV. Together they have lodged a lawsuit against the South African health minister, Manto Tshabalala-Msimang, and the nine provincial health ministers protesting against the South African Government’s management of mother-to-child transmission of HIV. They state that “the continued failure and refusal of the [health ministers] to make Nevirapine generally available in the public sector . . . and to plan and implement a nation-wide comprehensive programme to prevent mother-to-child transmission of HIV, is in conflict with the Constitution and unlawful”. In South Africa approximately 70 000 infections occur by mother-to-child transmission around birth each year. Two drugs, zidovudine and nevirapine, can prevent mother-to-child transmission and the manufacturer of nevirapine, Boehringer Ingelheim, has offered to supply the drug free of charge to governments for 5 years. However, the South African government says more studies are needed, and it has limited the use of nevirapine in the public sector to a few study sites. But in the private sector in South Africa doctors can, and do, prescribe nevirapine if indicated. The health minister justifies this situation by saying that the government has concerns about resistance to nevirapine, that despite using nevirapine transmission to the child can occur with THE LANCET • Vol 358 • September 1, 2001
breastfeeding, and that it is only appropriate to prescribe nevirapine in the setting of an overall plan for the care of women with HIV. The government is also known to be worried about the toxicity of antiretroviral drugs. None of these reasons justifies the government’s position. As the coalition states in their affidavit: “whether or not to prescribe Nevirapine is a matter of professional medical judgment . . . it is not a matter which is capable of rational or appropriate decision on a blanket basis.” They accept the urgent need for an overall plan for the care of women with HIV, but waiting until this is in place will cause many children to be infected. The second case, which echoes the concerns of the government over drug toxicity, is that being brought by Annet Hayman against Glaxo Wellcome SA, the importers of zidovudine. Her husband died in 1998 after having being diagnosed with HIV in 1997 and treated with zidovudine and lamivudine. He was apparently well before treatment. His widow claims in court papers served on the company that he “died as a direct result of the cellular toxicity of AZT [zidovudine]”. The court papers give a detailed rationale that alleges that zidovudine “has no proven anti-HIV effects in vivo countervailing against its proven profound cellular toxicity for patients taking it”. This case is not the first of such lawsuits alleging that people with HIV have died because of the treatment, not the HIV; a previous UK case was withdrawn before it came to court. These cases tell us something interesting about the politics of HIV. This disease is a tragedy for every family that it affects, but in Africa there is no time to indulge the luxury of wondering about the side-effects of anti-retrovirals. HIV does not discriminate in who it kills. By refusing to allow doctors in the public sector the freedom to prescribe drugs to prevent mother-to-child transmission, the government of Thabo Mbeki is discriminating against African men, women, and children who rely on public care. Had this happened under apartheid governments they would—rightly—have been horrified. AIDS is already wiping out one generation of South Africans; if the government does not act quickly, another generation will be lost. The Lancet 681
For personal use only. Reproduce with permission from The Lancet Publishing Group.
THE LANCET Volume 358, Number 9283
Taking HIV to court The decision on how to treat people with HIV infection has never been a simple clinical matter alone. From the beginning of this epidemic each new treatment has been scrutinised, and criticised, as never before, by scientists, doctors, and people with AIDS. The litany of accusations is long: not making new medications available quickly enough; use of drugs without adequate safety testing; drugs being too expensive; and pharmaceutical companies keeping a monopoly on the production of drugs. Increasingly, dissatisfied individuals and groups are resorting to legal action. Two cases currently underway in South Africa illustrate the extremes of opinion. The first case has been brought by a coalition of groups: the Treatment Action Campaign, an organisation that lobbies for affordable treatment for people with HIV infection; Haroon Saloojee, a paediatrician from Johannesburg on behalf of Save Our Babies—a group of paediatricians and maternal and child-health practitioners; and the Children’s Rights Centre, which represents children with HIV. Together they have lodged a lawsuit against the South African health minister, Manto Tshabalala-Msimang, and the nine provincial health ministers protesting against the South African Government’s management of mother-to-child transmission of HIV. They state that “the continued failure and refusal of the [health ministers] to make Nevirapine generally available in the public sector . . . and to plan and implement a nation-wide comprehensive programme to prevent mother-to-child transmission of HIV, is in conflict with the Constitution and unlawful”. In South Africa approximately 70 000 infections occur by mother-to-child transmission around birth each year. Two drugs, zidovudine and nevirapine, can prevent mother-to-child transmission and the manufacturer of nevirapine, Boehringer Ingelheim, has offered to supply the drug free of charge to governments for 5 years. However, the South African government says more studies are needed, and it has limited the use of nevirapine in the public sector to a few study sites. But in the private sector in South Africa doctors can, and do, prescribe nevirapine if indicated. The health minister justifies this situation by saying that the government has concerns about resistance to nevirapine, that despite using nevirapine transmission to the child can occur with THE LANCET • Vol 358 • September 1, 2001
breastfeeding, and that it is only appropriate to prescribe nevirapine in the setting of an overall plan for the care of women with HIV. The government is also known to be worried about the toxicity of antiretroviral drugs. None of these reasons justifies the government’s position. As the coalition states in their affidavit: “whether or not to prescribe Nevirapine is a matter of professional medical judgment . . . it is not a matter which is capable of rational or appropriate decision on a blanket basis.” They accept the urgent need for an overall plan for the care of women with HIV, but waiting until this is in place will cause many children to be infected. The second case, which echoes the concerns of the government over drug toxicity, is that being brought by Annet Hayman against Glaxo Wellcome SA, the importers of zidovudine. Her husband died in 1998 after having being diagnosed with HIV in 1997 and treated with zidovudine and lamivudine. He was apparently well before treatment. His widow claims in court papers served on the company that he “died as a direct result of the cellular toxicity of AZT [zidovudine]”. The court papers give a detailed rationale that alleges that zidovudine “has no proven anti-HIV effects in vivo countervailing against its proven profound cellular toxicity for patients taking it”. This case is not the first of such lawsuits alleging that people with HIV have died because of the treatment, not the HIV; a previous UK case was withdrawn before it came to court. These cases tell us something interesting about the politics of HIV. This disease is a tragedy for every family that it affects, but in Africa there is no time to indulge the luxury of wondering about the side-effects of anti-retrovirals. HIV does not discriminate in who it kills. By refusing to allow doctors in the public sector the freedom to prescribe drugs to prevent mother-to-child transmission, the government of Thabo Mbeki is discriminating against African men, women, and children who rely on public care. Had this happened under apartheid governments they would—rightly—have been horrified. AIDS is already wiping out one generation of South Africans; if the government does not act quickly, another generation will be lost. The Lancet 681
For personal use only. Reproduce with permission from The Lancet Publishing Group.