(ARV-) Free State? The moratorium's threat to patients' adherence and the development of drug-resistant HIV.

Abstract

Despite early fears that people living with HIV (PLWHs) in Africa would not be able to adhere to antiretrovirals (ARVs).1, 2 Research has shown that the proportion of PLWH reporting ≥95% adherence in sub-Saharan Africa is higher than in North America.3 However, maintaining adherence is a complex phenomenon and different ecological factors affect patient ability to access and adhere to ARVs: patient characteristics and context, ARV line regimen, clinical situation and the patient-health staff relationship. 4 In October 2008, the new minister of health announced that 550,000 PLWHs were on ARVs in South Africa, which is the highest number in the world.5 This achievement was recently tarnished by increasing alarm over the Free State public sector ARV programme. The Free State has the third highest HIV prevalence in the country (31%) 6. Since December 2008, the department of health has stopped initiating new patients on ARVs 7 because of drug stock-out and lack of funds. It is estimated that in this province 30 PLWHs are dying every day the moratorium continues.8While it is clear that this moratorium will increase morbidity and mortality, the loss of trust in the health system and the potential impact of the ARVs crisis on existing patient adherence should also be considered. Campero et.al. reported that patients already on ARVs share their medication with neighbors, relatives and/or friends who are delayed to start on ARVs 9. This practice could lead to drug resistance development in both people sharing the medication if they will have differential exposure to ARVs, 10-13 and on a public health level, raises serious concerns about drug failure, subsequent more expensive drug regimens and the spread of drug resistant strains of HIV. Patients’ perceptions of staff attitudes and waiting time were reported to be key factors for patients’ ARV adherence. 14 It is plausible that PLWHs will seek care in other provinces, and would consequently be required to return to outlying clinics on a monthly basis to pick-up their ARVs. Transport costs and the time needed to reach clinics are risk factors to both adherence and retention in care.15, 16 Patients currently on treatment – in the Free State and elsewhere - are understandably anxious about the health system’s ability to guarantee life-long access to ARVs. It was shown estimated that 300 000 people had died of AIDS in a preventable manner if the South African government had only responded to the AIDS crisis quickly in a coherent manner. 17 How the government now contains and repairs the damage being done in the Free State will be a litmus test for the long-term success of South Africa’s ARV programme.