When people living with HIV suffer drug resistance

In 2010, Ruth lost her mother to HIVAids. A few days after her mother’s death, Ruth’s father, Herbert Kamya, 52, was also diagnosed with HIV.
“After my wife found out she was HIV positive, she did not take any drugs. That is why she died early,” says Kamya. He says Ruth, together with her elder brother were also diagnosed with the virus.

In 2011, they were enrolled on antiretroviral treatment. The three family members ensure that they take their medication as prescribed by the doctor.

“We all take our medication at 7 am and again at 7pm. The two young ones take it under my supervision,” Kamya says.

CD4 count
Despite the adherence, Kamya says, in the past six months, Ruth’s health has been deteriorating.
“We were told by the doctor that her (Ruth’s)D4 count had dropped so low that we now have to visit the hospital after every two weeks so they can monitor her to ensure the CD4 count rises again,” says Kamya.

Dr Fairuz Naiga, a medical officer at Baylor Uganda, a non-profit child health and development organisation, says when a person tests positive, the hospital first analyses them for what is known as a baseline CD4 count (white blood cells), a complete blood count, liver and renal tests to determine how treatment can be administered.

Dr Naiga says the baseline test helps to determine when an individual can be enrolled on ART, as recommended by the Ministry of Health.

“For example, children below the age of 15 are supposed to be enrolled on ART as soon as they test positive, irrespective of their CD4. But adults usually can be started on treatment when their CD4 count is below 500,” explains the doctor.

She says recently approved guidelines by the World Health Organisation (WHO) recommend that people living with HIV be initiated on treatment when their CD4 count is below 500.

On the other hand, pregnant mothers, discordant couples, patients who have tuberculosis and hepatitis B patients should also be enrolled as soon as they test positive.

“At Baylor Uganda, though ART resistance is not common, we have patients like Ruth. We monitor them closely and aise on the kind of medication to take.”

Adds Dr Naiga: “We check drug adherence of our patients through pill balance counting and self-reports. Patients have to come with their drug balance while visiting the clinic.”

Dr Naiga says Ruth had a baseline CD4 count of 463, which increased to 800 after enrollment on treatment. However, it dropped again to 100.

“This is too low. It means that the first-line antiretroviral treatment has failed to work for her,” explains Dr Naiga, adding that treatment failure can also be detected through viral load count.

“If a person has a detectable viral load of more than 5000 copies per millilitre of blood plasma, despite good adherence to the treatment, it is an indicator that the drugs are not working,” says Dr Naiga.

“Viral load is a measure of the severity of an active viral infection, and can be calculated by estimating the live amount of virus in the body fluid,” Dr Naiga explains

Following Ruth’s treatment failure, Baylor Uganda switched her from first to second line medication.
Dr Naiga says: “Ruth’s viral load increased from 104,426 in July this year to over 145,000 currently. This has prompted us to change her to line-two drugs, which we hope will bring the viral load down and also increase her CD4 count.”

Ruth is one of 4,829 children and 64,154 adults currently receiving their ART at Baylor Uganda outlets across the country. Her father says he spends a lot of money on transport since the family lives in Paradise Island, in Mukono District.

“I spend most of the time coming to hospital since we all get our drugs from Kampala on different days,” says Kamya, adding that each visit costs him between Shs30,000 and Shs 50,000. He makes at least four trips a month.

Turning to second-line drugs
Dr Naiga says another patient, Deus, 13, also developed resistance to the first line treatment and was enrolled on the second-line drug in 2009. With the treatment proving successful, this reduced his viral load to non-detectable levels.

Apart from having to take several pills, Deus says he feels much better and has been able to concentrate at school.

Dr Naiga says the second-line pills are bigger in size, more expensive, and cannot be crushed, broken or mixed with water. This one obstacle, she says could hinder adherence to the drug.

“For younger children, the second-line line drugs are in the form of a syrup suspension, which should be stored in a refrigerator. This means that they cannot be moved from one place to another. For people living in rural settings where refrigerators are not easily accessible, this becomes a big challenge,” Dr Naiga observes.

Missing medication
Dr Anatoli Kamali, the deputy director of the Medical Research Council at the Uganda Virus Research Institute (MRCUVRI), says treatment failure is largely a result of patients missing some dosages and poor time management while swallowing the pills.

He, however, adds that among some individuals, drug resistance occurs after an infected person acquires a new strain of the HIV.

“Uganda has strain one as opposed to strain two in West Africa,” says Dr Naiga says, adding that primary resistance may also occur through sexual transmission or from mother-to-child through breastfeeding.

Generally, treatment failure results from non-drug adherence but health experts say that HIVAids patients should be given physical, spiritual, emotional and psycho-social support to ensure that they live a positive life.


SOURCE: Daily Monitor

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