Financial Gazette (Harare)
Dr Solomon Mutetwa
6 June 2002
opinion
THE announcement by the Zimbabwe government last week declaring a six-month state of emergency to tackle the HIV/AIDS pandemic has generated a lot of confusion not only with the general public and people living with HIV/AIDS but also in the medical fraternity and pharmaceutical companies.
Normally when a government declares a state of emergency, it implies assistance will be given to those affected. In the case of HIV/AIDS, the public would like to know whether the government is planning to provide antiretroviral drugs free. Or, is the government going to subsidise the cost of antiretrovirals and by how much?
The most burning question in the minds of people infected with HIV and those affected is whether antiretroviral drugs will become affordable. Currently the standard recommended triple combination costs over $100 000 per month, which is many times more than the monthly salary of an ordinary Zimbabwean worker.
The government needs to clarify exactly what the state of emergency means to the public. The government talks of paving the way for the importation of cheaper or generic antiretroviral drugs. Currently all the available antiretroviral drugs are still under patent and cannot be manufactured and sold as generics without incurring royalty charges to the pharmaceutical companies holding the patents.
Assuming the government by declaring HIV a disaster satisfies the conditions laid down by the Intellectual Property Rights regulations relating to the buying and manufacture of generic versions of patented drugs, does it have the capacity to manufacture or import these drugs considering the severe foreign currency squeeze we are in currently?
If the government intends to allow anyone to import these antiretroviral drugs, do we have the capacity to protect the public form counterfeit drugs? Is six months adequate to put all the legislation in place and import adequate quantities of antiretroviral drugs?
The public would like to know what happens after six months in terms of continuity and sustainable treatment. These are some of the questions the government needs to clarify.
I however think that declaring the HIV/AIDS epidemic a disaster was long overdue considering that the epidemic has been with us for more than two decades now and is claiming more than 2 000 Zimbabweans a week.
We have failed to take advantage of the development and knowledge of the treatment of HIV/AIDS with antiretrovirals which has resulted in the decline of morbidity and morality (death) from HIV/AIDS particularly in developed countries. In fact, in developed countries HIV infection has been turned from a progressively fatal disease to one of the chronic manageable diseases.
Despite such impressive progress in developed countries, HIV/AIDS in developing countries is still a death sentence in the long run. For example, Africa, especially sub-Saharan Africa, is home to 70 percent of the adults and 80 percent of the children living with HIV in the world and has buried 75 percent of more than 20 million people worldwide who have died of AIDS.
At the present moment, despite the lack of clear treatment guidelines, the use of antiretroviral drugs is increasing in Zimbabwe especially in the private sector and with employees of major international organisations based in this country. Because of the slowly increasing number of people on antiretroviral drugs, it is important that both the doctors prescribing those drugs and the patients taking them are well informed with accurate and up-to-date information.
There are certain basic principles that are very important to know relating to HIV/AIDS treatment. First and foremost, there is no cure for HIV/AIDS - antiretroviral drugs only prolong lives of people infected with HIV.
Second, treatment of HIV/AIDS is for life - that is once one is started on treatment one needs to continue taking the medication for the rest of one's life.
Third, antiretroviral drugs while very important are only part of a comprehensive treatment programme of HIV disease which encompasses the recognition and treatment of opportunistic infections.
Furthermore, attention to the many psychosocial and financial difficulties caused by HIV disease is also crucial and should be adequately addressed.
There are a number of stages to consider in the treatment of HIV-positive people. The first is during the early stages of the infection, the primary HIV infection or the acute retroviral syndrome stage.
About one-half of all patients experiencing the acute retroviral syndrome show signs and symptoms of illness two-six weeks after infection with HIV. Patients present with flue-like illness, which lasts longer than usual with, enlarged lymph nodes. Treatment at this stage is symptomatic; that is, we treat the symptoms of fever and pain with painkillers and so on.
The next stage is during the early stages of infections when there are essentially no signs and symptoms of HIV infection after the acute retroviral syndrome stage have disappeared. During this stage, which can last for years, the emphasis is on positive living - that is staying healthy by eating the current type of food, exercise, reducing stress, avoiding smoking, alcohol abuse, unprotected sex and early treatment of any other infection.
The next stage is when the CD4 cell count begins to drop because of the damage to the immune system by multiplying virus in the blood and tissues. During this stage emphasis is on preventive treatment (prophylaxis) of opportunistic infections as well as actual treatment of these infections.
Corrective measures during these stages have been shown to prolong life considerably.
The final stage is the use of antiretroviral drugs to fight the HIV infection directly. Anti-HIV drugs (antiretrovirals) work by reducing the amount of virus (HIV) in the blood and is reflected in a reduction in the viral load, which is the number of viral particles in the blood of an infected person.
When properly used, antiretroviral drugs can delay the onset of AIDS, prolong survival and interrupt transmission of the virus to sexual partners. Despite these obvious advantages, antiretroviral drugs have many limitations. They do not completely inhibit viral multiplication and the disease eventually continues to progress despite their use.
The reason why the death rate in Africa is high is because the majority of HIV-positive people are not on antiretroviral drugs compared to those in developed countries. The drugs are expensive and the vast majority of sick people cannot afford them.
The decision to start antiretroviral treatment and the selection of an antiretroviral segimen is complex as it requires consideration of factors such as the viral load levels, CD4 cell counts, potential drug instructions, concurrent medical problems, the long-term cost of the drugs, the patient's willingness to take multiple medication for possibly the rest of one's life.
Viral load
The viral load refers to the number of viral particles in the blood of an infected person. There are three viral load tests presently used in clinical practice and results can range from almost zero to over a million particles in a cubic millilitre of blood.
Lower numbers mean fewer viruses in the blood and less active disease whereas higher numbers mean more active disease. Achieving an unmeasurable viral load result is now the "Gold Standard" for successful treatment of HIV.
Viral load tests are available in Zimbabwe, but unfortunately they are very expensive - more than $12 000 per test. Most medical aid societies do not pay for viral load tests yet it is the most useful monitoring drug treatment and way of estimating the risk for progression to AIDS and death.
Medical aid societies however pay for CD4 cell counts, which is another very useful parameter for medical monitoring of HIV infection and treatment. When HIV attacks the body it targets and depletes CD4 cells (a type of white blood cell which coordinates the body's defence system) resulting in a weakened immune system unable to fight a variety of opportunistic infections.
Most adults who do not have HIV infections have a CD4 cell count between 100 and 1 500 cells per cubic millilitre of blood.
Antiretroviral drugs and combination therapy
There are currently three main classes of antiretroviral drugs. Combination therapy is based on taking these drugs together in various combinations. The recommended standard care consists of a regimen including three agents sometimes referred to as triple therapy.
Dual therapy consists of two drugs. Dual therapy is also effective and cheaper but its effectiveness is not sustainable over a long period. Furthermore, the chances of resistance developing more rapidly are greater with dual therapy.
The use of one antiretroviral drug - monotherapy - leads rapidly to drug resistance and should never be used for treatment of HIV infection except for the prevention of mother-to-child transmission.
Resistance is when antiretroviral medication becomes less effective or no longer works because the virus has got used to the drug or drugs in combination.
Adherence or compliance
Adherence or compliance is taking the medication in the right way at the right time regularly. Adherence is very important to think of before starting antiretroviral treatment because skipping only a few pills can trigger the emergency of drug resistant virus.
Such a development creates a worse problem than the initial infection because the resistant virus can overwhelm the individual taking the drugs and anyone else to whom the individual transmits the virus.
Dr Solomon Mutetwa is a lecturer at the University of Zimbabwe Medical School's department of medical microbiology. He is also into private practice and can be contacted at e-mail: smutetwa@mweb.co.zw
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