With a simple sign above the entrance and shelves of medicine that go halfway to the ceiling, Rasmei Sour is one of several storefront pharmacies that sit across from Wat Moha Montrei near Phsar Olympic.
But Rasmei Suor is unusual in that it is one of only a handful of pharmacies in Phnom Penh that sell antiretroviral AIDS drugs.
About 20 people come to Rasmei Suor each month to buy one of the 10 types of antiretroviral drugs that the pharmacy normally has in stock, salesman Hor Chhay said.
“Most people come just two or three times,” he said. “Some come regularly. They are usually rich.”
Anti-AIDS drugs are “easily available” in Phnom Penh for those who can afford them, according to Dr Lut Lynen of Sihanouk Hospital Center of Hope.
Treatment with anti-AIDS drugs, which can prolong the lives and improve the health of people with AIDS but can cost between $10,000 to $15,000 a year, have been available in Western countries since the mid-1990s. Doctors overseeing the treatment continually vary the dosage and change the kinds of antiretroviral drugs in order to avoid the development of drug resistance.
But many people who take the drugs do not consult a trained doctor, and that could cause problems as Cambodia prepares for the possibility of cheap, generic versions of anti-AIDS drugs becoming widely available in the next year. Health officials worry that current practices in Cambodia could create a widespread drug-resistant strain here. There is also the fear that patients would sell the cheap drugs on the black market, creating a greater potential for misuse.
“I think very soon you are going to see more generic drugs here,” said Subramanian Sridhar, country representative for Mega pharmaceutical company. “Cipla has started this, but other pharmaceutical companies are going to jump in. They don’t want to be left behind.”
“Unless this is regulated properly, people are going to abuse these drugs,” he said.
Next month, Medecins Sans Frontieres-France will begin a pilot antiretroviral drug therapy treatment program with about 10 AIDS patients at Preah Bat Norodom Sihanouk Hospital. The government intends to use the MSF program as a guide for writing a national protocol for administering antiretroviral drug treatments.
The free therapy is made possible by Cipla, an Indian-based pharmaceutical company that announced in February it will make triple-therapy drug “cocktails” available at cut-rate prices to 10 developing nations, including Cambodia.
The drugs have been offered to MSF at a special humanitarian price of $350 a year per patient or to governments at $600 a year per patient. The drugs could also be available to private individuals in Cambodia for $1200 per year.
At another Phnom Penh pharmacy, Pharmacie De Lagare, about 30 people a month buy anti-AIDS drugs, according to director Koy Paradis. The pharmacy, a large, air-conditioned store located near the railway station on Monivong Boulevard, carries about a half dozen anti-AIDS drugs, he said.
“Some buy for one week. Some buy for one month,” he said. “It depends on how much money they have.”
“At first, they come with a doctor’s prescription. Some just come two or three times and then stop because they want to have quick results. But I tell them that it is not like a toothache. I advise them that they must keep going.”
Staff from Center of Hope recently did an informal survey of Phnom Penh pharmacies and found that antiretroviral drugs are often bought without a doctor’s prescription. They also found that some drugs come without the original packaging, suggesting that they are fake, Lut Lynen said.
“We can’t be sure of the quality,” she said. “Now, it is uncontrolled [by the Ministry of Health], and people are sometimes wasting their money.”
Nuth Sokhom, vice-chairman of the National AIDS Authority, said that pharmacies are hard to control. But he promised the government will try to do a better job of regulating them.
Many of the drugs now available have been brought here from European countries, such as France, that have extensive public health systems, Subramanian Sridhar said. The drugs are sometimes over-ordered from the government and the surplus is then sent here to be sold on the black market, he said.
Dr Hak Chan Roeurn, the secretary of the HIV program at Calmette Hospital, said he treats about 20 patients a month with antiretroviral drugs in his private practice.
Patients usually come from the provinces and are from the upper- and middle-classes, he said. One patient comes from Koh Kong every month, for example. Another comes from Kompong Som.
Two other patients have been coming to him regularly since 1996, and are now in good health, he said.
“Before we begin, I ask them if they can afford the treatment for at least one year,” he said. But “most who stop treatment stop because of lack of money. Some stop because of the side-effects.”
Patients spend from $700 to $900 per month for a triple-therapy treatment, he said. Laboratory tests measuring the effectiveness of the treatment are performed every three to six months.
One obstacle is that there is not a guaranteed availability from pharmacies and drug distributors for some drugs. This can make it very difficult to keep a patient on the strict, complicated drug regimen that the treatment requires, he said.
Hak Chan Roeurn said he learned how to administer the antiretroviral treatments partly from attending overseas conferences and workshops. Pharmaceutical company representatives often come to Phnom Penh to answer questions from doctors about the drugs, he said.
“I think many physicians here now have knowledge of antiretrovirals,” he said.
Dr Hor Bunleng, deputy director of the National Center for HIV/AIDS, Dermatology and STD, said the government has “absolutely no problem” with AIDS patients who do antiretroviral treatments with trained doctors.
“If the patient consults with the doctor, then we expect no problem with the development of resistance,” he said.