Public service strike could impact ART adherence Living with AIDS # 309

KHOPOTSO: There are currently no public reports of people having to stop taking their antiretrovirals due to not being able to access treatment as a result of the current public sector strike, which has also affected services in government hospitals and clinics. However, concern is mounting that many patients may or already have interrupted their treatment. A concern is that more people could be affected if the wage dead-lock is not resolved soon, as on a daily basis, patients go to clinics and hospitals where health workers may be on strike. Dr Des Martin is a member and former President of the Southern African HIV Clinicians’€™ Society.


Dr DES MARTIN: Implications are that if people who are on antiretroviral treatment come to have their prescriptions refilled and are unable to access a clinic or pharmacy, there is a danger that they would have to interrupt their treatment. Now this has a couple of implications. The one is that as the treatment is interrupted, it means that the drug entry levels in the body fall and there is the rebound of the virus taking place within the patient. And so, the possibility of resistance developing to the antiretroviral medicines can occur.    


KHOPOTSO: When resistance due to treatment interruption occurs, it means that owing to the absence of medication the virus in the body was able to multiply such that when the ARVs are re-introduced, they are no longer able to fight off the virus. For antiretrovirals to work most effectively, a patient needs to adhere to treatment at all times.


Dr DES MARTIN: Some of the patients on treatment are very ill, with very low CD 4 counts. If they interrupt treatment, there is a very real danger that with the viral rebound that occurs on stopping treatment that the sudden loss of CD 4 cells, the immune cells in the body will occur, and it may precipitate an acute opportunistic infection which can have serious consequences, including death.  


KHOPOTSO: Martin says studies have shown that resistance can develop within 7 – 10 days of stopping treatment, and people with severely suppressed immune systems can be ill within a week of doing so. The Southern African HIV Clinicians’€™ Society has developed a four-point guide to follow in the event that patients are forced to interrupt treatment. These include, for those who can afford to pay, going to their nearest General Practitioner or private pharmacy with their empty medication bottles to request a repeat prescription. Generic medicine can be safely used to decrease costs. But it’€™s a fact that not all can afford even the cheapest generics.


Dr DES MARTIN: The natural inclination is to say ‘€˜okay, I’€™ll reduce dosages and then, I’€™ll be able to let my drugs last longer’€™. This is very dangerous because it leads to very sub-optimal levels of drugs and promotes resistance. So, that’€™s important that that doesn’€™t take place. And secondly, if one of the three drugs – as you know the regimen that is taken consists of three drugs – runs out, and the patient still has’€¦ (a) sufficient number of the other drugs, they may be inclined to say, ‘€˜well, I’€™ll just take the two drugs’€™. This is also dangerous because it is also sub-optimal therapy and it’€™s not endorsed. We would suggest that if that scenario arises that all medication should be stopped.            


KHOPOTSO: Once clinics and hospitals become functional again patients are advised to urgently go back and restart their treatment according to normal required doses. They are also warned not to increase or double the doses to compensate for missed medication. Martin regrets that this is not the best advice ever that patients could receive. He’€™s also concerned that the strike could have a negative impact on the government’€™s ARV rollout programme in the long run.


Dr DES MARTIN: We’€™re talking about individual cases here. But I think that it is the loss of confidence in the whole programme that is at risk, too, where people are unable to access their drugs, they would get turned away, get depressed, (and) these people are often depressed in themselves because of their illness, and to get them to come back to go on to their medication may also be a problem. So, at risk is the whole antiretroviral rollout, here. It’€™s much more than just the individual patient. I think it’€™s the whole rollout that’€™s at risk at the present time.


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