A crisis is emerging in the fight against Aids

A crisis is emerging in Africa in the fight against HIV because of increasing resistance to the most commonly used antiretroviral (ARV) drugs. “The problem is very serious. In our hospital we see more and more patients who after several years of treatment develop resistance to the medicine against the HIV virus”, says internist Furaha Lyamuya. He works at the Kilimanjaro Christian Medical Centre (KCMC), a regional referral hospital in Moshi, a small Tanzanian town at the foot of the Kilimanjaro. “In the hospital we can only see the tip of the iceberg. In the countryside there is fear, because many patients have already died because of the failure of antiretroviral therapy.”

The experience with the failing antiretroviral therapy in KCMC is confirmed in a study conducted in 36 countries between 1998 and 2015. Based on that research, the medical journal The Lancet Infectious Diseases (May 2016 issue)  publishes an important article about increasing resistance to one of the most widely used antiretroviral, tenofovir.

Co-author of that article is the Dutch fellow infectious diseases Raph Hamers, affiliated with the Department of Global Health of the Academic Medical Centre in Amsterdam. He is stationed at KCMC for several months as part of his research on HIV therapy resistance in Africa. “Treatment fails in one out of five HIV patients in Africa, and in six out of ten of them it is because the virus has become resistant to tenofovir.”

With Mirjan, a scrawny thirty year old woman, the drugs failed two years go. “I have been desperate because in 2005, I thought I had been saved from AIDS and then it began all over again”. She now receives other medications in the KCMC, the so-called second line. “Am I going to die?” she asks. “My husband has already died. I want to live at least until my children have finished school.”

In the eighties and nineties HIV caused widespread devastation in Africa. Worldwide, currently 37 million people are infected. 16 million of them receive antiretroviral therapy, of which 11 million reside in Africa.

After the turn of the century HIV treatment for Africans had been made available on a large scale for the first time, saving the lives of many millions of people. “Critics however cautioned the event of medical anarchy,” Hamers explains. “Because there is always the risk that the virus changes its form and becomes resistant. The risk rises significantly when the complex HIV treatment is provided in the context of a weak medical infrastructure. Patients need to be carefully monitored to avoid massive resistance. Unfortunately in Africa patients cannot always be thoroughly observed.”

Even in the more affluent West use of ARV’s may lead to HIV becoming resistant, the difference being that the patient there is regularly checked regarding the number of viruses he carries(so called viral load in the blood) to determine the right combination of his medications. If therapy fails, the patient is moved to a second-line treatment. In the West, a wide range of ARVs are available to the extent that where a third-line treatment and even a fourth line is possible. “In Africa the drugs has failed to work in 15 percent of patients receiving second-line. A third line is hardly available”, says Hamers.

Human error is the cause of the crisis. It is crucial to take  the ARV’s every day on a strict schedule to prevent resistance. Fatima (20 years) was tested HIV positive when fifteen. “Initially, I took my tablets strictly on time,” she says in the KCMC. “But when my parents failed to pay for my school fees, I had so much on my mind and I forgot those pills. Two years ago, I became ill and all the symptoms of AIDS returned. Now I’m on the second line, to be followed for me by the deadline.”

Occasionally due to weak infrastructures the drug is not delivered to clinics on time; only 65 percent of clinics in Africa are estimated to have continuous supply of HIV pills. In addition to the death of the patient with an untreatable virus a worldwide public health problem looms. Hamers warns that the resistant virus can be transmitted from a patient to healthy individuals: “We are seeing an increase in viruses that are already resistant even before the patient has been given any treatment. In Africa, it now turns out that about five percent of the newly infected people are infected with a resistant virus, in Uganda it is already over ten per cent.”

Sometimes sick patients present themselves at the KCMC with an already advanced stage of AIDS. “Why did we not notice them earlier and why did they not turn to us earlier?” wonders Kajiru Kilonzo, head of the department of internal medicine. “We try to explain to patients what their medication does to their body and yet they go to traditional doctors and refrain from taking their pills that we give them.” The concept of modern medicine is clearly still not widely accepted here.

Sixty percent of Tanzanians do not go to the modern day doctor, but rather to the traditional doctor. This deep trust rooted in traditional medicine, was shown five years ago. To the horror of modern medics a former priest in the village of Loliondo north of Moshi treated patients with a “miracle drug” against HIV, cancer, diabetes and other incurable diseases. Thousands of sick people came in long queues from far and wide to drink his magic potion. “Even a physician colleague of mine with diabetes went to drink this magic potion of Loliondo,” quips Dr. Kajiru Kilonzo. “Many Africans do not trust us modern doctors.”

So how can the tide be turned in Africa? Hamers calls for a reliable supply of medicines, so that the HIV treatment programs can facilitate patients to take their pills on a daily basis. He also argues for improved monitoring of patients and enhanced resistance testing. “Those who started treatment in recent years, should be enabled to live a healthy life for the next forty to sixty years. Let everybody be aware that the AIDS epidemic still exists. ”

Facts:
The standard therapy against HIV always consists of a combination of three or more drugs, because otherwise they become resistant. The HIV virus mutates fast and becomes thus easily resistant. In the West there are more than twenty antiretroviral drugs on the market. Physicians may opt for a variety of combinations, depending on the resistance of the virus in the patient.
People with HIV in Africa and other non-Western countries cannot afford such expensive medication. Only a limited number of cheaper combination therapies have been made available in these countries. Tenofovir is a widely used component. Now that resistance to this drug is emerging, there are only few alternatives.

Figures:

• 34 million people worldwide died already of AIDS since the beginning of the epidemic in the 80s.
• 37 million people are currently infected with HIV, the majority living in sub Saharan Africa.
• 1 of 5 HIV patients in Africa suffer from a failing ARV treatment.

This article was first published  in NRC Handelsblad on 21-4-2016