'Gloomy' outlook for Aids treatment

Only 60% of HIV/Aids patients in Africa still take the drugs they need to stay alive two years after starting treatment, researchers reported, noting a grim reason many stopped: death.

Of the patients found no longer to be taking the drugs after two years, 40% died and the rest missed scheduled appointments, failed to pick up medication or may have transferred to other clinics.

A small percentage stopped their treatment but continued to get other medical care at clinics where they started receiving HIV/Aids drugs.

“I don’t want people losing heart from this, even though 60% isn’t fabulous,” said Sydney Rosen, an assistant professor at Boston University’s School of Public Health, who led the study. The study was published on Monday in the Public Library of Science Medicine journal.

Nearly all of the people on the antiretrovirals would have died without them. “If you think of this in terms of deaths avoided and orphans avoided, then this could be a success story,” Rosen said.

The World Health Organisation estimated that HIV/Aids treatment programmes in the West retain about 80% of patients after two years.

The 60% for Africa is “a fairly gloomy conclusion”, said Dr Charlie Gilks, director of treatment at the WHO’s Aids department, who was unconnected to the paper.
“But considering the huge challenges we started with, a 60% retention rate is not such a bad benchmark.”

When the HIV/Aids pandemic hit Africa, many experts worried that the continent’s weak health systems would crumble under the stress. WHO’s “three by five programme” aimed to put three million people on antiretrovirals by 2005. By the initiative’s end, only 1,3-million were receiving them. Another 4,8-million patients still need the drugs, out of about 25-million people in Africa living with the virus.

Rosen and colleagues examined 32 publications reporting on 74 192 patients in 13 African countries between 2000 and 2007. Their report included many studies done in sub-Saharan Africa, particularly South Africa, which has the world’s highest number of Aids patients.

Experts noted the high numbers of deaths at the start of any treatment programme. In Africa, patients typically begin taking antiretrovirals when they are much sicker than Aids patients in the West.

WHO’s Gilks also said patients may be more likely to continue to take medication when they don’t have to pay for it. The study looked at programmes in which patients paid for drugs and others in which drugs were free or partially subsidised.

Gilks noted that the data in the studies researchers examined were several years old. He suspects that these days, more patients are taking their medication—though the evidence to prove that isn’t yet available.

“We clearly should be doing a lot better than 60%, but that is much more difficult than just identifying patients and getting the first pills into their mouths,” he said.

Establishing smaller health centres outside large cities might help.

“Once you get more than 1 000 to 1 500 patients, the services get congested and patient adherence rates go down,” said Dr Gilles van Cutsem, Aids project coordinator for Médécins Sans Frontières in Khayelitsha, South Africa. Van Cutsem was not connected to the study.

In big clinics where patients have to wait hours just to get their tablets, he said that the numbers of patients who stay on treatment often drops sharply.

There is also the problem of lack of transport. Many patients who desperately need the treatment are too sick to walk to the nearest clinic, and they have few options.

“If we only treat patients in big clinics, then we are sacrificing the ones who are very sick who cannot walk very far,” van Cutsem said.

Educating patients on the importance of their treatment is also crucial.

“We need to help patients have a clear understanding of why they should take their antiretrovirals and what will happen to them if they don’t,” said Dr Alison Grant, an HIV/Aids epidemiologist at the London School of Hygiene and Tropical Medicine.

Experts also said the study results underline the importance of reducing HIV infection in the first place.

“The best treatment is prevention,” said Daniel Halperin, an HIV/Aids expert at Harvard University’s School of Public Health.

Earlier this year, research showed that male circumcision can cut the risk of HIV transmission by up to 60%. Focusing on strategies like circumcision might enable experts to reduce the ultimate numbers of Aids patients.

“If we can prevent this epidemic, then that will solve a lot of the treatment issues eventually,” Halperin said. “Otherwise, we may not be able to keep up with so many patients.” ‒ Sapa-AP

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