Feature on fear over HIV drug resistance

Zambian health officials have warned of the emergence of strains of the HI virus that are resistant to current antiretroviral (ARV) drug treatment. Dr Ben Chirwa, director general of the Central Board of Health, said a recent laboratory study conducted at the University Teaching Hospital in the capital, Lusaka, had confirmed the drug-resistant strain, and its emergence was "clearly an indication that people are not being consistent with their medication." AIDS expert and former health minister, professor Nkandu Luo, told IRIN the problem was "immediate and urgent" because of its implications for drug policies and the cost of health care. "Drug resistance makes it difficult to treat patients ... if people are not getting better, we have to look at other options, which increases the cost of treatment. Zambia can barely afford to provide basic health care to its people - we do not need this additional burden," Luo said. Last year the government responded to the high cost of ARVs - around US $250 per month - by introducing heavily subsidised medication through the public health system for 10,000 HIV-positive people, at around $8 a month. In Chipata, one of the poorest areas in eastern Zambia, the challenge of resistant strains appears especially alarming, as information on drug adherence and compliance is often not provided by health officials. The community mainly comprises poor subsistence farmers, deeply rooted in a culture of polygamy and early marriages, with an HIV infection rate of 16.8 percent (compared to the national average of 19 percent). Suffering with recurrent pneumonia, Manida Mbewe, 34, says she was put on ARVs last September. After a couple of months of treatment, she began to feel better and stopped taking the medication. "I didn't see why I should continue the treatment when I was 'healed'," she explained. No one told her treatment was life-long, or that she could develop a resistant strain if she stopped and started her medication. Now that she knows, she has asked to be left to die. She has no income and relies on the goodwill of her relatives. "I cannot expect them - and neither do they have the capacity - to buy me medicine for the rest of my life, especially now that the medicines are not working. Let me just die and save everyone the trouble." It's not only disadvantaged people like Mbewe who find the prospect of life-long treatment daunting. Daniel Musoka, 43, a former supervisor at a major bank, was on ARVs for three years, paid for by his employer. When he was retrenched in 1999, as per its policy, the bank paid for only one more year of his treatment. He moved to his father's village in Chipata and continued to buy medicine with his retirement benefits, but the money ran out last year. "I had been off treatment for almost eight months. I had an idea about the dangers of stopping treatment, but I did not believe it could be that serious. I have found a job but, as is usual now, it's a one-year contract. It is unlikely that my contract will be renewed because there have been some complaints about my ill health," he said. Musoka has tuberculosis and is not responding well to treatment - the doctors have told him he has developed resistance to the medication and are now experimenting with various ARV combinations. "I am bitter that I face death because of a measly 50 [US] dollars (the cost of his monthly treatment)," he told IRIN. He feels the government should institute some kind of medical scheme for people on ARVs, so that they do not jeopardise their lives further by stopping treatment. He blames medical workers, too, for not emphasising the importance of continuity and the consequences of stopping medication. Musoka's health care provider, Nomsa Chembe, says some of her patients who cannot afford to buy their medicines from private chemists or pharmacies have, after a pause in treatment, switched to the cheaper government-supplied drugs provided by clinics and hospitals, with catastrophic results. "They do not tell us they were on other medications, because we, of course, cannot change therapies like pain killers. We only suspect this when we see they are not responding to medicines - by then it is usually too late to do anything but pray." She suggested better collaboration and a uniform procurement policy for ARVs between the government and private pharmacies, to avoid problems such as Musoka's. Chembe maintains that health workers provide adequate information on compliance and adherence, just as they are trained to do. Patients are told to take their medicines at regular times, eat before taking their doses, and drink at least three litres of water a day to hydrate the body because the medicines are strong. But the reality is that many patients forget to take their doses, thereby confusing their regimen, and find it difficult to access clean drinking water, Chembe said. Most areas are serviced by wells which do not always have fresh water. Food is also a problem - many people can only afford to eat once a day, Chembe noted. "This is why we receive complaints of nausea and vomiting and other side effects from the medication. People then stop taking ARVs because they think it is making them more sick." Initially, Chembe's clinic gave out packets of high-energy protein (HEP) mix with the medication, but stopped not only because the HEP donations ran out, but entire families of seven or eight began to depend on the 5 kg mix for sustenance, leaving the patient with little or nothing to eat. In the meantime, Luo is trying to get the government and aid agencies to move faster in addressing the emergence of resistant strains. "I am frightened. I heard President Mwanawasa saying government would provide ARVs for a further 100,000 people this year ... I am screaming 'stop', look at what is happening with just 10,000 people on treatment."