Can South Africa afford the price of not having climate-friendly antiretrovirals?

21 Nov 2024

Antiretrovirals like dolutegravir help keep people healthy. But their use adds to global warming, which drives climate change. Switching to newer forms of medicines can help to lower the carbon emissions from these medicines. But we don’t have enough to make this a reality. Here’s what has to change.

The anti-HIV drug dolutegravir is part of the world’s arsenal to end Aids as a public health threat by 2030.

But getting the antiretroviral (ARV) drug to 24-million people with HIV who use it as part of their entry-level treatment across the world — about 5.1-million live in South Africa, according to the health department’s figures — doesn’t come without a cost to the environment, a report from the United Nations-linked health innovation programme Unitaid shows.

When people stick to taking their ARVs — dolutegravir is one of three drugs in a three-in-one pill for people with HIV — the level of HIV in their bodies becomes so low that they can’t transmit the virus to someone else through unprotected sex.

This is called being virally suppressed, and is part of the so-called 95-95-95 United Nations goals. This strategy says that to stop Aids, 95% of people should know whether they have HIV, of those who test positive 95% should be on treatment, and of that group, 95% should be virally suppressed.

But at a panel discussion of the report at COP29 in Baku, Azerbaijan, on Thursday, public health experts said that products meant to give people healthy lives — from tuberculosis test kits and oxygen to medicines for HIV and malaria — were, at the same time, harming the environment. And extreme weather events, like floods and heatwaves, caused by this could make people sick and go hungry in the long run.

According to the Unitaid report, the use of dolutegravir would have emitted 2.7-million tons of carbon dioxide by 2030 since its widespread uptake after the World Health Organization recommended its use in 2016.

That’s roughly what Eskom’s coal-fired power plants emit in about five days.

This comes shortly after the Lancet Countdown report launched at the climate conference earlier last week showed that almost 5% of the world’s carbon emissions come from healthcare.

But reaching the 95-95-95 goals (for which the numbers currently sit at 86-89-93) doesn’t have to cost us the Earth, analyses show.

And, says Mitchell Warren, who heads up the New York-based HIV advocacy organisation Avac, while it is “terrific” to see the work that looks at the impact of HIV drugs on the environment, “from an HIV prevention and treatment perspective, the first priority needs to be to develop products that will work to ensure long, healthy lives for people living with HIV”.

Less is more

Making medicines, getting them to patients and dealing with the waste that’s generated in the process all emit carbon dioxide. This gas forms a layer in the atmosphere that traps heat rising up from the Earth’s surface after being baked hot by the Sun all day.

Because the heat can’t escape, the air heats up — much like in a greenhouse — and over time, the air gets warmer and warmer, leading to changes in long-term weather patterns on Earth.

While ARVs have been used in South Africa since 2004, the country started using a treatment plan in which patients had to take three pills to get the right combination of drugs to fight the virus in 2010.

Each of these medicines were made by a separate process, packaged in separate containers and transported from their factories separately — with each step sending carbon dioxide into the air.

Three years later, the health department’s treatment plan changed to a single pill that had all three drugs in one. Not only did it make it easier for patients to take the medicine, but it also meant that the amount of carbon emissions linked to the treatment was slashed — which, with about 2.7-million users in South Africa at the end of that year, was a big drop.

In 2019, the health department updated its plan again as newer medicines became available. Efavirenz, which is a drug that blocks the way HIV replicates itself, was swapped out for dolutegravir, also from this drug class. This came after evidence showed that it worked better at fighting the virus, had fewer side effects (which meant that people were more likely to stay on their treatment) and was cheaper.

Again, the change was good for the environment too.

According to another Unitaid report published this year, the use of efavirenz is linked to about double the carbon dioxide emissions as dolutegravir — about 595g per person per day for the efavirenz-containing pill compared with 223g with dolutegravir — mostly because of the chemical process for making the older drug.

Can the health department afford to slow climate change?

Getting people on treatment alone won’t get us to ending Aids, though; we have to stop new infections, too.

For that, there’s medicine that protects someone from getting infected in the first place, called pre-exposure prophylaxis. At first, this was available only as pills, which users mostly have to take daily when having unprotected sex and for seven days before and afterwards.

Since government clinics in South Africa started rolling out oral pre-exposure prophylaxis in 2016, the country has accounted for almost 40% of the world’s use.

As with drug development for treatment, newer prevention medicines have also come on the market in the past few years. One is an anti-HIV shot called long-acting cabotegravir, which is taken only every two months — instead of having to take daily pills.

Unitaids’s analysis shows that using this injectable form of pre-exposure prophylaxis generates 10 to 15 times fewer emissions than taking the daily pill because of the way the medicine is made, the small amount given per shot and it having to be taken only six times a year.

But at about £23.50 (about R540 at the current exchange rate) per shot, long-acting cabotegravir costs about four times more than the health department pays for a two-month supply of the daily prevention pill (which costs R64.50 for a month’s supply per patient).

And even though a donation of 231,000 doses over two years from the US government’s President’s Emergency Plan for Aids Relief, Pepfar, and the department’s willingness to buy the medicine if it’s at the right price could see long-acting cabotegravir becoming available in South Africa, it might not yet be the answer to slashing the carbon footprint of curbing HIV infections in the country.

That’s because the chemical process for making the drug means only small amounts of the medicine are being made at the moment. Putting together ingredients to build cabotegravir — the chemical that stops HIV from replicating and called the active ingredient in the long-acting cabotegravir shot — is “fairly straightforward”, Andrew Hill, a pharmacology expert who’s been working at universities and with pharmaceutical companies on the development of antiretrovirals for the past 30 years, told Bhekisisa in July.

But to make it into a long-acting form, it needs to be “ground down so finely that you get single drug particles rather than powder granules”, and this needs special equipment — which not many drug manufacturers can afford.

“Reducing the carbon footprint of ARVs won’t just be about shifting to injectables,” warns Warren, as these options are still “evolving” and aren’t “ready to scale to 40 million people living with HIV”.

But it can be, he says. “We just need speed, money and market size.” DM

This story was produced by the Bhekisisa Centre for Health Journalism. Sign up for the newsletter.

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Less is more

Can the health department afford to slow climate change?