Poor adherence to ART on rise

THE country’s fight against HIV is facing new challenges due to reports of misuse and mismanagement of anti-retroviral therapy as reflected by the ballooning cases of second-line treatment countrywide.

The National Aids Council (NAC) 2015 report reveals that people on second line treatment are 15 337, an increase from the 13 036 recorded in 2014.

Poor adherence to ART has been shown to be a major determinant of disease progression, mortality and health care costs.

While high adherence levels can be achieved in both resource-rich and resource-limited settings following initiation of ART, long-term adherence remains a challenge regardless of available resources.

Some people living with HIV stop taking their medication due to a number of reasons, among them fear of disclosure, stigma and discrimination whilst others listen to prophets who claim to cure the virus.

NAC communications director, Ms Medelina Dube, said non-disclosure to children living with HIV was also fuelling treatment failure.

“Defaulting is particularly rampant amongst young people born with HIV. This is because most parents or guardians do not tell them why they have to take medicines every day and they don’t even know they are living positively,” Ms Dube explained.

“Some are told that they have to take medicines because they have heart or kidney ailments. So when they don’t feel sick they don’t take medicines, thereby defaulting.”

Zimbabwe National Network of People Living with HIV (ZNNP+) executive director, Mr Dagobert Mureriwa, concurs that treatment failure is expensive.

“As a country, we have failed to put in place robust adherence and counselling services to monitor treatment failure. It’s cheaper for a country to have people in one treatment line,” he said.

“Yes, people respond to ARVs differently but due to the fact that 80 percent of our health sector is donor-funded, it becomes unsustainable to have treatment failures.”

Treatment failure is detected when one goes for viral load testing and is found to have more than 1 000 copies per mil. A decreasing CD4 count is also a sign of treatment failure as well as deterioration of one’s health.

Mashonaland East recorded 1 377 cases of second line ART patients, Mashonaland Central 477, Matabeleland North 455, Masvingo 1 448, Harare 3 684, Matabeleland South 645, Mashonaland West 1 430, Manicaland 2 155, Bulawayo 2 187 and Midlands 1 479.

People taking anti-retroviral drugs have been urged to adhere to their treatment requirements so that they do not develop resistance thereby incurring huge health care costs.

The director of the Aids and TB unit in the Ministry of Health and Child Care, Dr Owen Mugurungi, said HIV treatment success is hinged on sticking to specific times of taking the ARVs and on a daily basis without fail.

“Adherence is critical in suppressing the virus and the level of drug concentration should be maintained so that treatment becomes effective,” said Dr Mugurungi.

“If one defaults on treatment for whatever reason, the virus mutates and becomes resistant to drugs being taken. It then becomes expensive to move a patient from the first line of treatment to the second line.”

Currently in Zimbabwe most people are still on the first line of treatment, which is way cheaper and readily available in most public institutions.

Zimbabwe introduced ARV therapy in 2004. The country adopted the WHO treatment guidelines recommending patients begin treatment at a CD4 count of 500, compared to the 350 count in earlier treatment guidelines.

Pregnant women and infants living with HIV are being initiated on treatment regardless of their CD4 count. As such, trends show an increase of people living with HIV.

The number has risen to 1 412 790 in 2015 from 1 356 010 in 2011.

Regimens used for second line treatment include either a combination of tenofovir, lamuvidine, atazanavir/ritonavir or zidovudine, lamuvidine, atazanavir/ritonavir or abavacir, lamuvidine, atazanavir/ritonavir.

NAC used $9,7 million to procure tenofovir, lamivudine and efavirenz and $2 475 970 to buy atazanavir/ritonavir in 2015.

Treatment failures are attributed to lack of drug adherence and drug resist- ance.

“The treatment gap is being widened because second line treatment is more expensive than the first line. It is more desirable to have as few people on second line as possible,” added Ms Dube.

“NAC through its advocacy programmes has been reaching out to people across Zimbabwe, encouraging them to adhere to treatment. People are encouraged to take their medicines correctly and consistently as prescribed by health personnel.

“People are also encouraged to start treatment early before they fall sick. This means people should get tested for HIV as frequently as possible.”

The University of Zimbabwe Clinical Research Centre (UZCRC) had eight patients on third line ARVs as of September 2012 with an anticipation of not more than 100 people on third line in the country.

An increasing number of patients will eventually need third line medicines which are used when patients stop responding to first and second line treatment regimens.

A medical practitioner who agreed to speak on condition of anonymity said HIV treatment is a sad trend.

“Though it may seem like a small number to some but the fact is it is increasing and the country needs to be prepared to tackle the problem head-on,” said the medical practitioner.

“For those failing on second line the options are severely limited requiring rigorous trials by the health practitioner to determine which of the remaining drugs can be used.”

Third line ARVs include darunavir, raltegavir, etravirine and ritonavir.

Community Working Group on Health (CWGH) director, Mr Itai Rusike, said the ballooning cases of second line treatment could further widen the treatment gap.

“Second line treatment is expensive and the possibility of having a sizeable number on third line is condemning those in need of such treatment to death because they may never access treatment after this,” he said.

However, third line drugs are either unaffordable or unavailable in many developing countries.

“Drug resistance may spread to other related drugs thus limiting future treatment options,” added Dr Mugurungi.