Treatment Deficiencies

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

GAFFI will recommend and ensure that the following antifungal drugs are available to all countries that need them, based on caseload, at reasonable prices. GAFFI’s antifungal priorities are summarised below:

Antifungal Fungal infection(s) Infection impact Ease of use Need for monitoring Cost
Amphotericin B (IV) Cryptococcal meningitis induction Large Medium Renal function Variable
Flucytosine (oral) Cryptococcal meningitis induction Moderate Medium Blood levels, unless short course Variable
Liposomal amphotericin B (IV) Histoplasmosis in AIDS Large, as best agent of very ill patients Medium Almost none High
Itraconazole (oral) CPA, ABPA, SAFSHistoplasmosis ModerateLarge Medium Blood levels, liver tests Moderate
Natamycin (eye drops) Fungal keratitis Large Easy (frequent) No Not available in most countries


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 and flucytosine  – and made this publicly available (www.gaffi.org/why/burden-of-disease-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).

In summary as of April 2016, the following table summarises antifungal availability for the countries that GAFFI could identify data for (Kneale et al. In press):

Disease/status Intravenous only Intravenous and oral
Amphotericin B Fluconazole Itraconazole Flucytosine
Countries where not licensed 22/155 (14.2%) 0/143 4/121 (3.3%) 89/123(72.4%)
Countries where not available 42/155 (27.1%) 1/133 (0.75%)* 8/121 (6.6%) 94/120 (78.3%)
Population with no access to antifungals 480,963,000 (6.62% World) 22,920,000 (0.32% World) 151,652,000 (2.09% World) 2,898,245,000 (39.9% World)

GAFFI is working with partners to improve access to these medicines.