DR Mannaseh Phiri
8 March 2004
column
Lusaka — MORE and more Zambians are living fuller healthier lives that would have otherwise have ended were it not for anti-retroviral drugs (ARV's).
If the country was not so deep rooted in denial, and if there was not so much stigma associated with HIV/AIDS, many would publicly testify to the fact that anti-retrovirals have given them another lease on life.
A small number of people do die, however, even after starting ARV's. They die not from the ARV's or their side effects, but rather from the pre-existing problem of a severely depleted immune system. This is usually so when the drugs are started in people who have advanced or long standing HIV infection or AIDS. Says Dr Des Martin, president of the Southern African HIV Clinicians Society (of which a Zambian branch is in registration), "Typically, these patients are not dying from the drugs but from the underlying problem of a severely compromised immune system. In a small number of cases, especially those with very low immunity, starting ARV's sets off an Immune Reconstitution Inflammatory Syndrome." As the drugs begin to restore the immune system, they may re-activate existing organisms in the body, like TB bacteria for example, flaring up a fatal TB process.
To be effective, ARV's must be taken in combinations containing at least three drugs - hence the names 'triple therapy' or 'combination therapy' or 'cocktail'.
For the fortunate majority religiously adhering to taking ARV's as instructed, and in the correct combinations, the results are quite dramatic and easy for all to see. People who were wasted, sickly, moribund and totally incapacitated are soon able to return to happiness, well-being, good health and to work. Time off work for visits to doctors' clinics and hospital admissions is drastically reduced.
The results of successful ARV treatment are really most fulfilling for all involved; the doctor, the person receiving the treatment, authorities at work, friends, relatives etc.
There is however an unfortunate spin-off, a negative sting in the tail, which is developing in Zambia. Because some people are doing so well on these ARV's, cases have been known where the patients themselves recommend and share their medications with their undiagnosed sick friends or relatives!
I have come across two such cases where people have, without being seen by any doctor, and without having any blood tests done, started themselves on ARV's based only on the fact that their relatives were doing well on them. If this practice is widespread, and I suspect that it is, it must be condemned in the strongest possible terms. It must be exposed and be stamped out forthwith. It is not only very dangerous for the people taking the drugs without prescription and medical advice, but more so for our society as a whole.
Such un-prescribed, unchecked and unmonitored abuse of these powerful, life-saving, essential drugs can lead to the development of dangerous ARV-resistant strains of HIV. If such strains develop and spread in Zambia, it would spell doom for the future management of HIV infection and AIDS. As it is, the choices of ARV combinations available to prescribing doctors are already limited by cost, availability, tolerability and convenience of dosage. Creating widespread resistance to the drugs we are using now would further limit doctors' choices of drugs that can be prescribed. It would be devastatingly fatal to Zambia's entire HIV/AIDS treatment programme - even just as it is beginning to take off.
The epidemiological implications are too ghastly to contemplate. Studies elsewhere show that if HIV develops resistance to a specific ARV drug, it will most likely be also resistant to other drugs from the same family or group - even where these other drugs from the same group have not been tried on the patient yet. (This means it is potentially possible to create resistance to drugs that may not even have arrived in the country yet!)
To understand how ARV's work, we need to first understand and reflect on the very basics of HIV infection.
When a person is infected with HIV, the virus enters their blood stream where it seeks out and destroys their CD4 cells. These are the white blood cells that are the building blocks of the immune system - the body's natural ability to fight off infections. HIV destroys the CD4 cell by entering it; completely taking it over and then making it reproduce more viruses. Each newly produced virus then finds a CD4 cell of its own, enters it, takes it over, destroys it and makes it produce more copies of virus, and so on. As more and more viruses are produced, less and less CD4 cells are available to fight off infections and the infected person develops AIDS and eventually dies.
There is, as yet, still NO CURE for HIV - even though there is no shortage of claimants to the contrary. What the ARV's do is to slow the progression of HIV by halting the multiplication process of the virus and thus stopping the subsequent development of AIDS. They save the CD4 cells by preventing the HIV from multiplying in them. The virus is not killed. It is merely prevented from multiplying into very large numbers and destroying the immune system's CD4 cells. Numbers of viruses are thus merely kept in check, not totally eliminated. This is why it is so vitally important and crucial for people on ARV treatment to keep taking the drugs everyday as instructed no matter how well they may feel. If they break the treatment, the viruses will immediately begin to enter the CD4 cells, destroy them and begin to multiply again.
So, the primary goal of ARV treatment is to improve and prolong the quality of a person's life by restoring and/or preserving a functional and effective immune system. This, as we have seen, is achieved by keeping the numbers of virus down by preventing it from multiplying. As long as the immune system is functioning well, there will be little or no opportunistic infections and other "AIDS-defining" illnesses which are what cause death.
When ARV's have been properly prescribed, the doctor looking after the patient will need to do regular blood tests to monitor the progress as the drugs restore the immunity. In sophisticated laboratories, such as the Virology Laboratory at UTH, tests can be done that measure the "viral load" - counting the actual number of virus particles per unit volume of blood. Other laboratories in the country are able to count CD4 cells. If treatment is progressing well, the viral load should be going down as the CD4 count rises. Even where these two tests are not available, such as in most parts of our country, there are other blood tests that measure the white blood cell levels that are used and are quite acceptable for monitoring treatment.
This is one of the other important reasons why people should not start taking ARV's without a doctor's supervision. The doctor may need to change the medicines if blood tests indicate that treatment is not being successful - if, for example, the CD4 continues to fall instead of rising steadily. A person taking ARV's without prescription has no scientific means of measuring success and may carry on taking a combination of drugs even though it is ineffective.
Furthermore, all HIV medicines can produce bad, unpleasant and undesirable effects in people taking them - so called side effects. However, contrary to popular belief, not everyone gets these side effects and those who get them do not suffer them equally. Some people get worse side effects than others while some may not experience any side effects at all. In those where side effects do occur, they are mostly manageable and usually only last the first few weeks of taking the medications. In some cases though, the side effects may be so severe and/or life threatening that the doctor may have to change the combination of medicines.
Some of the drugs must be taken in lower doses to start with, under supervision, before increasing the dose to maintenance levels. A person taking un-prescribed and unsupervised ARV's may not be aware of these requirements or of the side effects and could place their life in grave danger.
Successful ARV therapy therefore depends on a very close supportive relationship between the prescribing doctor and the patient where all issues and doubts surrounding ARV's are regularly discussed fully and understood. The doctor should be easily available and accessible to the patient at any time - particularly in the early stages of treatment.
All ARV treatment should be prescribed and properly supervised by trained personnel. ARV's should not be available on request and without prescription from pharmacies, drug stores, untrained personnel, relatives etc. People will continue to seek to obtain ARV's without prescription because they are in denial and/or are afraid of stigma and discrimination. They are not willing to have VCT, get a proper diagnosis and go on professionally supervised combination therapy. Those that are on successful treatment remain secretive about it. Secrecy will only encourage a black market around ARV's and as we have seen, this could be dangerous for the whole country if drug resistance creeps in.
We need more people - especially prominent Zambians - to come out in the open about their HIV status and the benefits they are getting from ARV's. We just need to discuss everything around HIV/AIDS more, frankly, openly and all the time if we are to lift our country out of its depth of denial.
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