Cryptococcal meningitis: treatment needs to be cheaper and more available

Treatment for a common AIDS-related infection, crypotococcal meningitis, is still out of reach and too expensive in many countries, say doctors from South Africa and London’s St George’s Hospital in a letter published in the September edition of Lancet Infectious Diseases.

The group point to the example of amphotericin B, which until July 2005 cost almost four times as much in South Africa as it did in the United Kingdom, and to its recommended companion drug, flucytosine.

Supplies of amphotericin B have been inconsistent due to lack of demand in the developed world, whilst flucytosine has not been registered in South Africa since 1996, when Roche stopped producing it. Although generic versions exist, bioequivalence studies are needed to test whether products from China are suitable, and donated products from the United States and Europe require lengthy regulatory scrutiny before they can be imported into South Africa.

Crypotococcal meningitis affects people with advanced HIV disease, and its course can be rapid without prompt treatment. Starting antiretroviral therapy may not be enough to ward off the infection, and the authors say that the results of a Thai study make the case for using aggressive antifungal therapy to control and eliminate the infection, with long-term antiretroviral therapy to guard against relapse.

In South Africa the price of amphotericin B was reduced from £12.69 to £2.26 a 50mg vial by manufacturer Bristol Myers Squibb following lobbying from the Treatment Action Campaign, the AIDS Law Project and the Southern African HIV Clinicians Society.

However, the authors urge governments and regulatory authorities in developing countries to look at ways of creating sustainable access to drugs needed to treat opportunistic infections, such as fluconazole (for candidiasis and cryptococcal meningitis), amphotericin B (for cryptococcal meningitis) and ganciclovir (CMV disease), by using the provisions of the 2004 TRIPS agreement and compulsory licensing to make the products more easily available.