Why African countries are still struggling in HIV war

Most HIV patients in African countries have lower viral suppression than those in high-income countries due to low rates of viral load testing, a study has shown.

The study done in Zambia and Malawi also confirmed that patients who got their medication after every six months instead of every three months were less likely to have complications and were stable.

The study comes at a time when the country is struggling with a shortage of drugs and most hospitals are rationing the medication. Patients have reported being given the drugs for only a month or even weeks.

Hospitals have also been giving patients drugs either in brown envelopes or in polythene papers and only those who carry their containers to the hospitals are given the drugs in them.

Currently, manufacturers are packing drugs for three months in one bottle, 90 packs. This means that when a patient picks a pack, it is enough for three months. Before, manufacturers would do 30 drugs in a pack for a month.

However, to lower the cost of transportation and storage, the production has shifted to 90 packs.

Patients have been complaining that hospitals are rationing their drugs. It means that hospitals are now breaking the container seals and dividing the drugs among patients.

The Zambia and Malawi research found that 18 per cent of patients who received the current standard of care in their clinics experienced a period of over 60 days without any antiretroviral therapy (ART) during the year of the study.

This decreased to 14 per cent in patients whose appointments were every three months and to 8.5 per cent less than half the rate in those with six-monthly appointments.

No intervention

The study dubbed INTERVAL was conducted in HIV clinics in Malawi and Zambia and 9,118 patients were enrolled.

Patients involved in the study had to be on first-line ART, with an undetectable viral load for the previous six months, not need care for other conditions, and not be pregnant or breastfeeding.

The clinics were split into three groups in each country. In the first group, no intervention was made and patients received the same standard of care as before.

In the second, they received regular three-monthly check-ups and ART refills; in the third, six-monthly.

The researchers looked to see if patients visited their clinics at other times for non-HIV-related issues and in fact very few did.

In the standard-of-care arm, most patients were receiving ART refills from once a month to every three months, though a few started getting six-monthly appointments during the study period.

The most common dispensing interval in this group was three months and 59 per cent of patients had a refill this often. However, they were not necessarily the same patients every time, and the intervals varied.

It is, therefore, important to note that this study measured the improvements in ART continuity due to both greater regularity in appointments, by comparing the standard-of-care and three-monthly groups, and by lower frequency of appointments, by comparing the three-monthly and six-monthly groups.

The researchers concluded that the inconvenience and cost of more frequent clinic visits meant that patients were more likely to miss appointments.

It also states that a gap of more than two months off drugs was a quite strong predictor of virological failure.

Get drugs

Health Acting Director-General Patrick Amoth, in a directive to the counties, stated that the rationing was caused by a shortage of drugs in the country.

He directed county health executive members to issue all patients on Tenofovir/Lamivudine/Dolutegravir (TLD) 300/300/50mg booked for appointment in March and April 2021 with one month of stock.

The directive is still in place. Patients are still getting drugs for only one month.

“Currently, as per the programmes, eligible patients are offered up to three months of drugs to minimise regular facility visits while those who are unstable requiring more frequent follow up are seen more frequently,” states the statement.

The programme, Dr Amoth said, has reviewed the current numbers of patients on TLD versus the current product supply pipeline and to ensure uninterrupted supply of ART medication, they should be given for one month.

The decision was arrived at after it emerged that there were stock-outs and a taxation stalemate between the United States Agency for International Development and the Health ministry.

What it means is that even for the one month guidelines by the ministry, hospitals are unsealing the containers and dividing the drugs among patients.