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A Morte de Camões, Domingos Sequeira - c. 1825, Museu Nacional de Arte Antiga, Lisboa

Portugal and the reality of ARV treatment

HDN Key Correspondent, Lisbon, Portugal

More than 50,000 people are living with HIV in Portugal today. These figures, reported at the 5th National AIDS Congress mid-October 2004, clearly outnumber the UNAIDS data reported in July this year (high estimate of 36,000). The national daily "Diário de Notícias" on October 19 reported that HIV prevalence among pregnant women in the Lisbon area is now above 1%. With this level, according to current UNAIDS definitions, Portugal now falls in the category of countries representing a "general epidemic". Prior to 2000, Portugal did not report HIV cases, thus making analysis of the epidemic difficult. However, the data available today make Portugal the country with the highest HIV incidence in Western Europe.

Not such a big deal, a cynical might think - treatment is widely available for free in a Western European country. Sadly, the reality is complex and very different. 40-50% of people under treatment in Portugal are resistant to one or more antiretroviral drugs, and up to 15% of which seem to be multi-resistant to all available ARVs. A study discussed at the recent National Congress revealed that in the southern region, 77 patients were treated with a bitherapy. On a national level, the number of patients under bitherapy is expected to be at 1,800.

According to the virologist Ricardo Camacho from the Egas Moniz Hospital in Lisbon, patients are all too often treated by doctors who have little or no experience in HIV. Continuous education mechanisms, CEM programmes do not exist. Physicians, once licensed, are allowed to practice until their burial.

Effective salvage therapies are difficult to prescribe or sometimes come too late. Portugal has a unique, very bureaucratic drug distribution system. Any drug distributed through the national health system has to be budgeted for by the hospital where a patient is treated. If the needed salvage regimen doesn't figure in the budget, then there is no salvage therapy. Meanwhile, patients die.

These problems became evident at a Fuzeon information meeting, organised this week by Roche Pharmaceuticals in Lisbon. Several case studies and treatment histories from local hospitals were discussed in detail. At a time were 4 protease inhibitors were licensed in Europe, Portuguese doctors prescribed NRTI-only regimens. When resistances occurred, one NRTI was exchanged with a next one, three, four times in a row, carefully building up resistances to the whole range of this substance group over the years. Later inclusion of other substances, still one by one, did of course not break this vicious cycle.

It was hard to believe that no one in the room protested or even made a remark about such regimens against all recommendations. Did it have to do with the fact that the head of the responsible department at the Hospital Santa Maria, where these patients were treated, was also chairing the meeting?

Rather unsurprising: the very same professor explained that the problems with multi-resistant patients were due to bad adherence. This statement, at least, provoked a reaction from the guest speaker, Dr. José Mallolas, from the Hospital Clínico in Barcelona. He politely reminded professor Antunes of reasons other than bad adherence that can lead to resistance.

Luis de Camões referred to his country in the epic poem 'Os Lusiadas': "Onde a terra se acaba e o mar começa. E onde Febo repousa no oceano..." (Where the land ends and the sea begins. And where Phoebus* sinks in the ocean...). - This Phoebus was probably tired to bring its light to the very last corner of Portuguese hospitals.

Lisbon, October 14, 2004
HDN Key Correspondent

*Phoebus: by name of the ancient Greek god Apollo, representing the sun.

References:
1. UNAIDS/WHO/UNICEF: Epidemiological fact sheet Portugal, 2004 update. Sep 1, 2004. Retrieved October 20, 2004, from UNAIDS/WHO/UNICEF via www.unaids.org/html/pub/publications/fact-sheets01/portugal_en_pdf.htm
2. Fernanda Câncio, "Há mais de 50 mil portugueses com HIV" - Conversa da semana, Diário de Notícias, Lisboa October 16, 2004 Fernanda Câncio, "Lisboa com epidemia generalizada" Diário de Notícias, Lisboa October 19, 2004