Desperately seeking third-line medication

Marie Gisèle Tientcheu, 30, an AIDS activist, has developed resistance to second-line antiretroviral (ARV) treatment, and has had to look outside Cameroon, her home country, for the medicines she needs.

Her story has received a lot of media attention in Cameroon, and has thrown the spotlight on growing concerns that as countries scale up their treatment programmes, more and more people living with HIV are expected to develop resistance to their drug regimens and will need prohibitively expensive second-line drugs.

Although the number of people who have become resistant to the second tier of drugs is still relatively small, the challenge is trying to keep these numbers down. According to many specialists, poor adherence to regimens is the biggest cause of the development of strains of the virus that are resistant to medication.

"For various different reasons [including fear of exposure], some patients forget to take their treatment, or miss out doses; others give up on their treatment and go to see healers or prayer groups, where they are promised a speedy and lasting recovery," said Dr Flavien Ndoko, who is in charge of the AIDS programme run by GTZ, the German government's aid agency.

In August this year, GTZ, in partnership with the Ministry of Public Health and the national AIDS commission, launched an awareness campaign encouraging patients to stick to their treatment regimen.

An estimated 55,000 HIV-positive Cameroonians are receiving ARVs, of which more than 4,000 are being treated at the central hospital (Hôpital central de Yaoundé HCY) in the capital, Yaoundé, but there are no official statistics on the national resistance rate.

A study in 2007 on patients receiving care at this hospital revealed that 4.4 percent of patients were developing resistance after a year of treatment.
Dr Charles Kouafang, the head of the hospital's AIDS unit, said the rate of resistance had fallen from the 2002 level, when a similar study revealed resistance of 16.2 percent after only eight months of treatment.

"In 2002, the lack of treatment adherence was due to the high cost of ARVs," he noted. The situation improved after the government introduced free treatment in 2007, but "the fact that cases of resistance still occur is a public health concern," Kouafang said.

Tientcheu stopped taking her ARVs for seven months in 2005 because she could not afford them. She then enrolled for treatment at a local hospital in Yaoundé, where she could get her medicines more cheaply, and began receiving second-line ARVs.

Two years ago, her doctors began suspecting that she was developing resistance to the ARVs because her body was no longer responding, but she could not take the test to confirm this straight away as she didn't have the money. "The test is still very expensive [150,000 CFA francs or US$322], and is not within reach of many people living with HIV," she told IRIN/PlusNews.

After months of waiting, Tientcheu was finally able to take a free test in 2007, as part of a project run by Médecins Sans Frontieres (MSF), an international medical NGO.

I felt like I was dying ... This never happened in four years of treatment, and this is the hardest to live through

But after taking a different range of second-line ARVs for a few months, her CD4 levels (which measure the strength of the immune system) stopped rising, and her doctors began switching her medication with no success. She now has nowhere to turn and is constantly experiencing opportunistic infections.

"One of the three drugs prescribed by my doctor really affected me; I felt like I was dying," Tientcheu said. She feels too weak to travel long distances and has virtually been confined to her bedroom for three months. "This never happened in four years of treatment, and this is the hardest to live through," she said.

The search for treatment continues

Tientcheu is not the only Cameroonian dealing with the problem of resistance to second-line medication. "It is imperative that third-line ARVs be distributed in Cameroon," said Caroline Kenkem, the Deputy Executive Secretary of the Cameroon network of people living with HIV (RECAP+).

This is unlikely to happen anytime soon, said Alain Fogué, president of the Cameroon movement for advocacy and access to treatment, a lobby group. "I don't think the authorities are planning to provide third-line ARVs in Cameroon; I don't even know if they are aware of this situation, because managing the second-line protocol is hard enough."

At the end of June 2008, Tientcheu decided to stop her treatment and start looking for countries that could give her the medication she desperately needs, which is often the only solution for patients in this situation.

Her pleas for help were heard by Cameroonians living in Europe, who have set up a solidarity fund to support her and other patients in the same position, and regularly send her packages of medication.

But this solution is temporary, so organisations of people living with HIV in Cameroon have launched an appeal to the authorities to find a sustainable solution.

"We feel there is no real policy on medication, or on providing care and support for patients," said Fogué. "It feels like we're trying to get our voices heard, despite many years of fighting and demonstrations for political action."

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