Print version ISSN 0256-9574
SAMJ, S. Afr. med. j. vol.99 n.6 Cape Town Jun. 2009
(ARV-) Free State? The moratorium's threat to patients' adherence and the development of drug-resistant HIV
Ziad El-KhatibI; Marlise RichterII
IDivision of Global Health (IHCAR), Karolinska Institutet, Stockholm, Sweden, email@example.com
IISteve Biko Centre for Bioethics, University of the Witwatersrand, Johannesburg, firstname.lastname@example.org
To the Editor: Despite early fears that people living with HIV (PLWHs) in Africa would not be able to adhere to antiretrovirals (ARVs),1,2 research has shown that the proportion of PLWHs reporting >95% adherence in sub-Saharan Africa is higher than that in North America.3 However, maintaining adherence is complex, and several factors affect patient ability to access and adhere to ARVs: patient characteristics and context, ARV regimen, clinical situation and the patient/health staff relationship.4
In October 2008, the new Minister of Health announced that 550 000 PLWHs the highest number in the world were on ARVs in South Africa.5 This achievement was recently tarnished by increasing alarm over Free State province's public sector ARV programme. The Free State has the third-highest HIV prevalence (of 31%) in the country.6 Since December 2008, the province's Department of Health stopped initiating new patients on ARVs7 because of out-of-stock drugs and lack of funds. An estimated 30 PLWHs are dying every day in the province while this hiatus continues.8 The moratorium will increase morbidity and mortality, but the loss of trust in the health system and the potential impact of the ARV crisis on existing patient adherence also need to be considered.
Campero et al. reported that patients already on ARVs share their medication with neighbours, relatives or friends who experience delays in receiving ARVs.9 This practice could lead to the development of drug resistance in people sharing medication if they consequently have differential exposure to ARVs,10-13 and raises serious public health concerns about drug failure, subsequent and more expensive drug regimens, and the spread of drug-resistant strains of HIV.
Patients' perceptions of staff attitudes and waiting times were reported to be key factors for patients' ARV adherence.14 Conceivably, PLWHs will seek care in other provinces, and would consequently be required to return monthly to outlying clinics to pick up their ARVs. Transport costs and the time needed to reach clinics are risk factors to adherence and retention in care.15,16 Patients currently on treatment in the Free State and elsewhere are understandably anxious about the health system's ability to guarantee lifelong access to ARVs.
An estimated 300 000 people might not have died of AIDS if the South African government had responded to the AIDS crisis quickly and in a coherent manner.17 How the government proceeds to contain and repair the damage being done in the Free State will be a litmus test for the long-term success of South Africa's ARV programme.
1. Moatti JP, Spire B, Kazatchkine M. Drug resistance and adherence to HIV/AIDS antiretroviral treatment: against a double standard between the north and the south. AIDS 2004; 18 (suppl 3): S55-61. [ Links ]
2. Check E. Staying the course. Nature 2006; 442: 617-619. [ Links ]
3. Mills EJ, Nachega JB, Buchan I, et al. Adherence to antiretroviral therapy in sub-Saharan Africa and North America. JAMA 2006; 296: 679-690. [ Links ]
4. Bangsberg DR, Ware N, Simoni JM. Adherence without access to antiretroviral therapy in sub-Saharan Africa? AIDS 2006; 20: 140-141. [ Links ]
5. Speech by the Minister of Health Ms Barbara Hogan at the HIV Vaccine Research Conference (http://www.doh.gov.za/docs/sp/sp1013-f.html). In: Vaccine Research Conference; Cape Town 13 - 16 October 2008. Pretoria, Department of Health. [ Links ]
6. National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa 2006. Pretoria: Department of Health, 2007. [ Links ]
8. Thom A. 30 dying every day in the Free State HIV Clinicians (http://www.health-e.org.za/news/article.php?uid=20032192). Health-e (accessed 19 February 2009). [ Links ]
9. Campero L, Herrera C, Kendall T, Caballero M. Bridging the gap between antiretroviral access and adherence in Mexico. Qualitative Health Research 2007; 17: 599-611. [ Links ]
10. Bangsberg DR. Preventing HIV antiretroviral resistance through better monitoring of treatment adherence. J Infect Dis 2008; 197: S272-S278. [ Links ]
11. Bangsberg DR, Acosta EP, Gupta R, et al. Adherence-resistance relationships for protease and non-nucleoside reverse transcriptase inhibitors explained by virological fitness. AIDS 2006; 20: 223-231. [ Links ]
12. Boulle A, Ford N. Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges? Sex Transm Inf 2007; 83: 503-505. [ Links ]
13. Gardner EM, Sharma S, Peng G, et al. Differential adherence to combination antiretroviral therapy is associated with virological failure with resistance. AIDS 2008; 22: 75-82. [ Links ]
14. Dahab M, Charalambous S, Hamilton R, et al. 'That is why I stopped the ART': Patients' & providers' perspectives on barriers to and enablers of HIV treatment adherence in a South African workplace programme. BMC Public Health 2008; 8:doi:10.1186/471-2458-8-63. [ Links ]
15. Murray LK, Semrau K, McCurley E, et al. Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: a qualitative study. AIDS Care 2009; 21: 78-86. [ Links ]
16. Tuller DM, Bangsberg DR, Senkungu J, Ware NC, Emenyonu N, Weiser SD. Transportation costs impede sustained adherence and access to HAART in a clinic population in southwestern Uganda: A qualitative study. AIDS Behav 2009; 13 March [Epub ahead of print] [ Links ].
17. Chigwedere P, Seage GR 3rd, Gruskin S, Lee TH, Essex M. Estimating the lost benefits of antiretroviral drug use in South Africa. J Acquir Immune Defic Syndr 2008; 49(4): 410-415. [ Links ]