The Minefield - Initiating anti-retroviral therapy in Africa.

Didi Emokpare MD Regina, Canada

In a series of articles concerning the treatment of HIV/AIDS in our resource-poor Africa, I wish to review the current thought on treatment protocols and their potential complications when applied incorrectly.

The world view on treatment of HIV/AIDS has shifted significantly over the past year alone. With the announcement by the Canadian government last year, of legislation allowing for companies to produce low-cost generic antiretroviral medicines, a new hope for millions of people living with HIV/AIDS was born. African governments have flocked to the altar of treatment programs, promising to save our dying nations.

Critical questions seem to have been sidelined in the quest to treat masses of people with these drugs. The catchy jingles and feel-good slogans fail to portray one crucial fact. Africa does not presently have the infrastructure to sustain widespread use of antiretroviral therapy. In fact, we may be heading for an increase in the spread of resistant HIV strains, as wholesale treatment programs fail to correctly address basic scientific and even socioeconomic aspects of treatment.

The holistic approach to treatment means we must treat the patient as a whole, not in terms of specific disease – mind and body. It is baffling that we are still obsessed with treating patients with ART, and fail to provide medicines for nausea and other side effects of these powerful drugs. How do we expect these drugs to work, if the patients cannot tolerate the medications?

I received a letter from Funmi, a young Nigerian girl on ART therapy provided by the government. She had run out of money for the drugs, and had not received medicines in 2 weeks. A well-known but sadly little publicized fact is the speed and ruthless efficiency of the HIV virus to quickly become resistant to medications, once some doses of medication are missed. Even under the best of conditions – adequate nutrition, social and mental support and proper medical care, patients may still experience poor response to the virus.

How does Funmi know now, that even if she gets the medicines today, that they will still work? Truth is, she doesn’t. She believes in what we tell her. That she’s lucky to be on the medicines, that she may have a new life. We are not telling her, that we cannot afford to monitor her viral loads or check to see if the virus she has is resistant to the medications she’s taking. She believes in hope, and that is basically what’s keeping Africans alive.

Our desperation is apparent, our motives noble, and our zeal great to help ourselves, but we may just be jump-starting a new AIDS epidemic fueled by a drug-resistant virus. Over the course of even a few months, the entire continent could face a new wave of the HIV virus, resistant to multiple ART cocktails. In Africa, for the same reasons, we have drug-resistant malaria, and multiple drug-resistant Tuberculosis.

African nations have now funneled massive amounts of money into ART programs, at the neglect of the crumbled public health institutions. We are neglecting to treat Tuberculosis and Malaria, still the biggest killers of HIV/AIDS patients.

Where are the legions of Tb treatment workers? Where are the companies contracted to eliminate the malaria-carrying mosquito, with the same vitality they throw into HIV/AIDS research? Where are the voices of government officials building water wells, and opening factories to produce infant formula or intravenous fluids, so that our children stop dying from diarrhea? Where are the private NGOs and foundations handing out multivitamins and anti-nausea drugs, so that an AIDS patient can at least keep his food down?