Challenges of antiretroviral treatment in resource-poor settings

In a 2001 U.S. Congress Hearing, Chief U.S. Aid A. Natsios publicly stated that if Africa was given antiretroviral treatment (ART) for its HIV/AIDS epidemic, its citizens wouldn’t know how to take the pills on time because they measured the hour by the sun.

“Africans do not know what watches and clocks are,” said Natsios. “They do not use western means for telling time. They use the sun. These drugs have to be administered during a certain time during the day and when you say 10:00, people will say ‘what do you mean by 10:00?’”

But contrary to Natsios’ statement, the complication of administering ART in Africa has nothing to do with the sun. Antiretroviral treatment has a possibility of serious side effects and it requires a high level of adherence on a daily basis. The drugs have been labeled as “unforgiving” in many medical studies if they are not used properly, and resistance may develop in patients that could compromise the entire treatment. For medical clinics, the cost of ART together with the cost of monitoring patients taking these drugs poses a major financial challenge to public health programs, particularly in developing countries where a lack of medical infrastructure and human resources could limit the access to professional and safe ART.

The overall goal of antiretroviral treatment is to better the life of people living with HIV/AIDS, as there is no known cure or vaccination for the virus. But scientists and medical practitioners have debated for years on the best time to start treatment to prevent immunologic damage and adverse side effects from drug toxicity. Cost of treatment, too, must be factored into the argument, as some resource-limited countries must give priority treatment to patients with obvious immunologic damage before moving on to the less urgent cases.

Dr. John A. Idoko, Department of Medicine at the University of Jos, spoke about the benefits of early antiretroviral treatment in Nigeria this week at the annual Harvard-PEPFAR conference on HIV/AIDS prevention. According to Idoko, a delay in initiating ART increases the risk of toxicities—such as skin rashes and bloated stomachs—in a majority of patients. Thus he proposes that medical staff initiate ART when patients have a CD4 level of +350 mm3.

“Firstly, there’s an issue of toxicity. Toxicity is the number one reason that patients stop adhering to their drugs—and the lower the CD4 count when given medication, the higher the toxicity rate,” said Idoko. “Secondly, those who die from HIV/AIDS usually start their medication at lower CD4 counts. Thirdly, the medication given for higher CD4 counts is stronger, less toxic, and more convenient.

“So with all these factors, why not start medication later?”

Nigerian government health guidelines state that patients must have a CD4 count of below 350 and show symptoms of HIV/AIDS before they can receive antiretroviral treatment. But many patients with a CD4 count of between 200 and 350 don’t show symptoms, said Idoko, and cannot receive their needed treatment because of these guidelines.

In the United States, the government changed their health guidelines in less than one year to reflect recent studies and to state that medical facilities can treat patients with 350 CD4 count and monitor patients at lower levels. Dr. Idoko advocates that the Nigerian government follow in the U.S.’s footsteps and make earlier ART part of national health policies and guidelines.

“We want to be suppressing the virus as much as possible,” said Dr. Idoko.

Apart from finding the perfect time to administer ART, enforcing patients’ adherence to ART is always another challenge in resource-poor settings. If a bus driver cannot afford to miss work, he will find it extremely difficult to trek to the clinic each month and wait several hours to pick up his medication. Or, if a mother has to choose between feeding her six children and buying antiretroviral treatment for herself, she will likely pick her family over her own health.

This financial reality stirs up big problems for patient adherence, but many clinics and hospitals in Nigeria are working their way around it. The Jos University Teaching Hospital provides inpatients with transportation to and from the hospital to lower their financial burden. The hospital also encourages local governments to support their HIV-positive staff with transportation to the hospital, and encourages their HIV/AIDS support groups to approach the government for grant money. According to Idoko, “the government does help with funding when it can, but overall it’s not doing enough.”

In addition, the Jos University Teaching Hospital assigns treatment partners to each patient to not only provide financial support, but also emotional, psychological, and physical support. And though the challenge of providing ART to patients in Nigeria and other resource-poor settings continues, scientists, researchers, and doctors have shown that the solutions lie in adherence, access, and support, and not in clocks or the sun.

*Reported by Amanda Hale