2018 marks the 30th anniversary of World Aids Day. South Africa has made great strides towards the global 90-90-90 targets (90% of adults living with HIV tested, 90% of people living with HIV on treatment and 90% of those on treatment have viral suppression by 2020).
But, the scale of the treatment programme and the concentration and possible accumulation of HIV antiretrovirals (ARVs) in the physical environment could be creating new health problems. Research studies have identified ARVs in South Africa’s water.
Project K5/2594, a three-year Water Research Commission (WRC) funded project being conducted by the University of the North-West, looks at the presence, concentrations and risk implications of ARVs in South African water resources. Preliminary results indicate the presence of ARVs in treated wastewater, in ground water, in tap water and in aquatic life, including fish.
South Africa has the highest number of people living with HIV – more than seven million. Of these more than four million are receiving treatment, according to the World Health Organisation’s 2017 data. ARVs are the largest sold medicines in the country.
Analyses of drinking water in South Africa shows that a range of pharmaceuticals and personal care products are in our water, including antibiotics, antidepressants, artificial sweeteners, illegal drugs and ARVs. One of the routes through which these pharmaceuticals enter our water sources is through human excretion. The body does not absorb all components of ARVs, so the parts left behind leave through urine and faeces, resulting in waste treatment plants being the biggest contributor to water with ARVs.
ARVs also reach our water through the improper disposal of unused or expired drugs. Medication flushed down drains directly enters the water system. If it’s thrown away into landfills, water-soluble components seep into ground and surface water. Additionally, local ARV manufacturing was established to ensure the adequate and timely supply of the drugs. The production and distribution processes of ARVs could also see drugs or their components ending up in our water system. Water treatment plants are unable to manage drug waste through human excretion or improper disposal.
Across the world, numerous studies have shown that pharmaceuticals and personal care products are present in water sources, but there is still no clear evidence or knowledge of the effect on human health.
The absence of evidence though does not mean that humans are safe from any adverse effects of continual exposure to drug waste in water. For example, low concentrations of HIV drugs consumed through drinking water could create a situation for drug resistance once consumed by people with HIV who are not on treatment. And even a slight possibility needs to be ruled out considering the large number of people who rely on a limited number of drug combinations.
More research is also required to determine the effect of continued exposure to various mixtures of pharmaceuticals: What happens when antibiotics and antidepressants combine with ARVs in our water supply?
Additionally, changes in water quality have a direct effect on water security and sustainability and consequently on our country’s economic and social goals.
Adequate policy responses and actions are required to ensure that South Africa stays on track to meet its development goals as outlined in the National Development Plan Further, goal 6 of the sustainable development goals calls for access to clean water and adequate sanitation for all by 2030. This means ensuring sustainable management of water resources and availability of water for all citizens. Unchecked drug waste could put the attainment of this goal at risk.
Pharmaceutical companies should put in place strict measures to ensure safe disposal of drugs. Adopting a sense of stewardship, responsibility and accountability can contribute to improved water and sanitation management and governance while contributing to sustainable development. In their production, manufacturing, and distribution, businesses can adopt good practices that protect water quality.
While government continues with its robust HIV treatment programme, the heavy financial investment made should be safeguarded. Close monitoring of the amount of ARVs and their concentration in the physical environment must be carried out to mitigate the risk of secondary health issues. Government support for research into the effect on human health of ARVs in the aquatic environment is critical.
Individuals also have a prominent role to play. Consumers should be aware that every tablet has a long-term effect on the environment. For those on ARVs, unsafe disposal could be risking the long-term success of their treatment. The safe disposal of unused drugs by returning them to pharmacies or treatment centres should become obligatory.
Ultimately, lowering the infection rate is the best way of minimising any health risks of ARVs in water sources. Reducing infections reduces the number of people taking ARVs and decreases any long-term risks of ARV waste in water. In 2017 however, there were 270 000 new HIV infections in South Africa according to UNAIDS, the alarming rate of new infections means that the treatment burden and its effects will be with us for more years to come. Continued emphasis on preventing infections is therefore paramount to improved health outcomes for all.
As we mark World AIDS Day for the 30th time, in addition to promoting testing and encouraging treatment, we need to make a collective effort to ensure that ARV drug waste does not compromise our collective health whether our status is negative or positive.
Dr Eunice Ubomba-Jaswa is a research manager at the Water Research Commission