The virus in most cases responds to the ARVs and its activities are more or less paralyzed in the presence of adequate blood levels of the drug. Unfortunately some strains of the virus become resistant especially when the blood levels of the drug become suboptimal for any reason and the virus is able to multiply in the presence of the drug. Some of the reasons include poor adherence to the drugs, fake or expired drugs and stock outs of drugs at clinic pharmacies so that people on ARVs are unable to get their next supply of drugs.
HIV-positive patients about to start antiretroviral treatment are warned not to skip even the occasional dose of their medication because of the virus' ability to mutate rapidly and become drug resistant;
When one contracts a strain of HIV resistant to some life-prolonging medicines, treatment options become limited. A recent study done in five African countries found that transmitted HIV drug resistance may be on the rise in Africa. ¹
The sad fact is that a number of people who are yet to start treatment with ARVs may already be infected with a resistant strain of the virus and therefore may be doomed to fail their treatment from the outset.²
If resistant strains of HIV proliferate and spread among our population, more people will begin to fail their treatment and the number of deaths due to HIV may begin to increase.
So how do we tackle this issue and ensure that the gains we have achieved in successfully treating HIV do not become reversed in the near future?
Governments and leaders in the health sector need to continue to pay due attention to HIV treatment programs and ensure regular drugs supplies for all clients on ARVs. It would also be very helpful if the tests needed to detect drug resistance are made widely available and cheap. If a patient is failing treatment, doctors mainly rely on viral load (a measure of the amount of HIV in the blood) and CD4 count tests (a measure of immune system strength) to determine whether they may be failing to respond to first line ARVs and need to be switched to second-line drugs. Generally speaking, the availability of viral load testing in African countries is very limited, and patients are kept on first-line treatment long after it becomes useless.
Governments should therefore persist in showing commitment to making such tests available, if possible without cost, so that doctors can monitor resistance and treatment failure much more effectively.
Pharmacists need to be trained and retrained on the essence of ensuring a functional drugs and commodity supply chain systems, through proper and timely reporting. They should also ensure that clients are not given expired drugs. Doctors, nurses and adherence counselors need to be equipped with knowledge and counseling skills to encourage their clients to be adherent to ARV drugs.
All people on ARVs should be constantly reminded of the importance of taking 100% of their drugs all the time according to prescribed dosages. It is not easy to take drugs for 5 days to treat a mild chest infection, how much more taking ARVs for life. Therefore people on ARVs should be empathized with and supported to ensure that they do not miss their medications.
Employers should be willing to allow their HIV positive employees to go to their clinics on appointed days and pick up their drugs. During public holidays, hospital staff should make arrangements to ensure that clients who run out of drugs during the holidays can get replenishment.
If an HIV positive person falls sick and has to be admitted, caregivers must ensure that even while on admission, the person has access to his ARVs. And in facilities offering HIV treatment services, any client who fails to come for his drugs or clinical consultations at the appointed time should be tracked and monitored closely so that he or she can be supported to take ARVs continuously.
All these strategies and procedures are important to ensure that we curb that ravaging effects of HIV. If HIV is allowed to develop resistant strains because of irresponsible HIV/AIDS treatment infrastructure and systems, the eventual result will be that resistant forms of HIV that do not respond to current life-saving drugs will spread among us.
In real life terms, the scenario will look like this:
A young man who is HIV positive has an appointment to see the doctor and pick up his next months supply of drugs on Monday. His current supply of drugs will run out by Monday evening. However Monday and Tuesday have been declared public holidays and when he gets to the facility, he finds that the HIV clinic and pharmacy are closed. By Wednesday morning he has already missed 2 or 3 doses of his ARVs. The reduced levels of the ARVs in his blood stream allow the virus to begin to multiply and in so doing, they develop mutations that enable them to become active even in the presence of ARVs. The virus becomes resistant. This resistant strain continues to multiply and their population in his blood increases over time.
During one night of reckless abandon he has unprotected sex with a young lady and she becomes infected. Two years later, her immune system becomes severely depressed by the virus and she starts falling sick. After initial tests the doctor recommends that she begins ARV treatment. However because she is infected with resistant HIV, she does not respond to treatment and she gets even sicker. Unfortunately, tests to detect resistant strains of the virus are not routinely available in most general hospitals. She is referred to a special center for the test but it’s going to cost her up to 200,000 naira.
And so the story goes…
In another case, the fellow on ARVs could have missed his doses because he was not properly counseled on the importance of not missing his medications. Or he may just be non chalant and irresponsible regarding his medications. At the end of the day, what happens is that the virus wins the battle and all efforts to treat and save both him and the poor young girl are in vain.
When I look at the future and I think about HIV, what do I see? I hope to see a future where resistant strains of the virus are few and detected early. I hope to see a future where our hospitals and clinics are equipped to be able to carry out important tests at affordable costs. I hope to see a committed and responsible government that cares about its people, especially those living with HIV and AIDS. I hope that in the future, my children, and their children, will grow up safe and healthy, in an environment that is coordinated and equipped with knowledge and strategies to win the fight against HIV.
That is the future I hope to see.
References:
¹ http://www.liebertonline.com/doi/full/10.1089/aid.2010.0030
² http://www.plusnews.org/Report.aspx?ReportId=90431
