Many countries do not have any antifungals for GAFFI’s target diseases, or the price is excessive. One of the key drugs, amphotericin B, takes some experience to use, and training is required. Flucytosine and natamycin eye drops are not registered in many countries, especially sub-saharan Africa, and so are unavailable. Itraconazole is approved, but not used, and is too expensive for long term use. It is also best monitored to ensure adequate concentrations in blood. The reliability of generic itraconazole formulations is not known.
Echinocandins (caspofungin, micafungin and anidulafungin) are the optimal therapy for serious Candida infections, including Candida auris, but are unavailable or excessively priced in many countries.
The WHO has not listed most antifungals as Essential medicines, thanks to GAFFI’s applications. The following antifungal drugs need to be made available in all countries at reasonable prices. GAFFI’s antifungal priorities are summarised below:
|Antifungal||Fungal infection(s)||Importance||Ease of use||Need for monitoring||Cost|
|Amphotericin B (IV)||Cryptococcal meningitis induction||Life saving||Medium||Renal function||Low|
|Flucytosine (oral)||Cryptococcal meningitis induction||Life saving||Medium||Only in renal failure, neonates||Variable|
|Liposomal amphotericin B (IV)||Histoplasmosis in AIDS||Life saving||Medium||Almost none||High|
|Itraconazole (oral)||CPA, ABPA, SAFSHistoplasmosis||Reduces symptoms||Medium||Blood levels, liver tests||Low to moderate|
|Voriconazole (IV and oral)||Invasive and chronic aspergillosis||Life-saving||Medium||Blood levels, liver tests||Moderate to high|
|Natamycin (eye drops)||Fungal keratitis||Sight-saving||Easy (frequent)||No||Not available in most countries|
ACCESS TO ANTIFUNGAL MEDICINES
GAFFI’s vision to make at least generic antifungal agents available to at least 95% of the population by 2025 is in its ’95-95 by 2025’ Roadmap.
GAFFI has now mapped antifungal registration, availability and price for 4 key generic antifungals – amphotericin B, fluconazole, itraconazole, voriconazole, flucytosine and natamycin eye drops – and made this publicly available https://www.gaffi.org/antifungal-drug-maps/. Amphotericin B, fluconazole and flucytosine are now on the WHO Essential medicine List. GAFFI has re-applied for itraconazole capsules to be placed on this list (link).
GAFFI is working with partners to improve access to these medicines.