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.
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


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 multiple generic antifungals – amphotericin B, fluconazole, itraconazole, voriconazole, flucytosine, and natamycin eye drops and the echinocandins – and made this publicly available https://gaffi.org/antifungal-drug-maps/. Amphotericin B, fluconazole, flucytosine, itraconazole, voriconazole and natamycin eye drops are now on the WHO Essential medicine List.

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