South Africa braces for new wave of drug-resistant HIV

Nov 29, 2007, 16:08 GMT

Johannesburg - As Christmas approaches the prospect of millions of South Africans making their way home to rural areas for the holidays gnaws away at Fr Stefan Hippler.

What should be a happy time for a Catholic priest is tainted by worry because he knows that Christmas is a time when many HIV/AIDS patients stop taking their treatment.

'When people go back to their home place many don't take their medication because their relatives don't know (about their HIV status) or because it's inconvenient,' says German-born Hippler, who has been working with AIDS patients in Cape Town since 1999.

'So there's a period of between two to five weeks where some people don't take their medication.'

After years of foot-dragging by the government on the rollout of life-prolonging antiretrovirals (ARVs), the country with the largest number of HIV-positive people now boasts the world's largest AIDS treatment programme.

Around 380,000 people are getting free ARVs from the state. While that still leaves around 1 million people, mostly in rural areas, in need of treatment, the size of the programme is already throwing up issues.

Chief among them is how to get hundreds of thousands of people to take their medicine every day, several times a day, for the rest of their lives.

Antiretrovirals are extremely unforgiving when it comes to compliance. Some AIDS drugs require adherence levels of 97-98 per cent to be effective - a tough ask for some people on 10 pills a day, some of them extremely toxic.

Mpolokeng Mabuse, 26, member of a HIV support group in Pretoria, describes how her upper body started to balloon and she began to get pains in her legs when she started ARVs. Eventually she had to be switched to second-line drugs.

'Since I started ARVs four years ago I've only missed them once when I forgot to take them, but I know one lady who stopped for six months and started again this week,' she confides.

A recent study by the Boston University School of Public Health showed that around one third of people receiving HIV medication in sub-Saharan Africa died or discontinued their treatment within two years.

Those who stopped treatment cited a variety of reasons - some had too far to travel to clinics to pick up their drugs, others feared the stigma of taking drugs that revealed their HIV status.

In South Africa, some people come off the drugs to let their CD4 count (measure of the strength of the immune system) slide to qualify for a state disability grant, Andrew Mosane, a campaigner with the Treatment Action Campaign AIDS lobby group, says.

Even one or two missed doses a month can lead to drug resistance, in which case the patient has to be switched to much pricier second- line drugs.

'You need to be very compliant,' says Lynn Morris, head of the AIDS unit at the National Institute for Communicable Diseases, noting that 70 per cent of people who fail their drug regimen develop resistance.

Even the most scrupulous patients are likely to develop resistance within a few years, leading Health Director General Thami Mseleku to warn of an imminent phase of 'major resistance.'

'The challenge is going to be huge because of the cost - it's 500 per cent more - to move to the second-level regimen of drugs,' Mseleku said in August.

Natalie Mayet, a doctor at BMW's manufacturing plant outside Pretoria, never thought she'd be warning patients to think twice about taking ARVs.

Mayet has been treating AIDS patients since 1987. These days her advice to HIV-infected workers is: 'If you cannot commit, don't take it, because you are causing more damage if you take it in a haphazard way than if you don't take it at all.'

BMW provides free HIV testing and care for close to 3,000 workers. Up until now only about three or four workers out of around 160 have dropped out of treatment since the company began its AIDS programme, Mayet says.

'On the whole compliance has been very good. But it's still very early days,' Morris, of the National Institute for Communicable Diseases, says.

'If we don't stop it (resistance) here we're going to have a situation like that of extremely drug-resistant TB,' Hippler says, referring to the almost incurable strain of tuberculosis creeping across South Africa.

'We must ask how we can strengthen the healthcare system to give as much assistance as possible to the patients. We also have to discuss when it is ethical to stop treatment.'