HIV Treatment in South Africa - Starting treatment, adherence

It is many years since AIDS denialism came to an end in South Africa and antiretroviral therapy (ART) was rolled out in the public health sector. Now South Africa has the largest HIV treatment program in the world.1"Treatment coverage is increasing, but there is more work to be done", https://www.groundup.org.za/article/hiv-treatment-programme-doing-well-long-way-go/

South Africa has adopted a Test & Treat policy for HIV

South Africa has adopted a Test & Treat policy for HIV

Four point five million people in South Africa had started taking ARV drugs by June 2018.2"South Africa launches campaign to expand access to HIV treatment", www.unaids.org/ensscentre/featurestories/2018/december/south-africa-access-hiv-treatment This is 20% of all people who had started treatment worldwide. By June 2018 the total number of people remaining on ART therapy in South Africa was 4,224,982.3"South Africa: Has President Ramaphosa Kept His 2018 State of the Nation Promises",  https://allafrica.com/stories/201902060652.html

Fewer infants are being infected with HIV. In 2017/18 a polymerase chain reaction (PCR) test done at around 10 weeks showed a 0.95% positivity rate for all babies born to HIV positive women. 4"Department of Health 2017/18 Annual Report https://pmg.org.za/committee-meeting/27432/

In 2016 South Africa's HIV policy changed to a "test and treat" policy. This means that everyone diagnosed with HIV should be started on ART regardless of CD4 count. But according to the Thambisa model of the South African HIV epidemic more than 40% of people with HIV were still not on treatment in 2017.

On World AIDS Day 2018 a new campaign Cheka Impilo, was launched to initiate an additional 2 million people on HIV treatment by 2020.

Adult antiretroviral therapy (ART)

Goals of antiretroviral therapy

The goals of ART are to:

  • provide maximal and durable suppression of viral load (VL)
  • restore and preserve immune function
  • reduce HIV related infectious and non infectious morbidity
  • prolong life expectancy and improve quality of life
  • prevent onward transmission of HIV
  • minimise adverse effects of the treatment.

What drugs do people need to take when on ART

There is more about the drugs people need to take when on  HIV antiretroviral treatment.

Why do some people diagnosed with HIV not start treatment?

There are a number of different reasons why people diagnosed with HIV do not start treatment. Some patients do not always accept their diagnosis, are not always willing to start lifelong treatment and have (unnecessary) lingering concernsa about the safety of ART. Also, the public health system is not easy for patients to understand. There are also long queues and health workers often do not communicate clearly.

It is believed that some people may be reluctant to start ART because they have heard all sorts of bad things about the side effects of ARVs, and this makes them reluctant to start treatment. But antiretrovirals have improved dramatically over the last 20 years. For the vast majority of people who start treatment, there are no side-effects or they are minor. Antiretroviral treatment is life-saving, usually easy to take and once it has reduced the virus to undetectable levels in the blood, makes it almost impossible to transmit HIV.

Simple things such as the nearest ART clinic being too far away or not being able to afford the taxi fare to get there are obstables that people may have to overcome to access treatment. Also, some groups of people such as teenagers, men who have sex with men or transgender people may find that the clinic isn't a welcoming space.

Does everybody who starts treatment continue on it?

There are conflicting views on this. Some people believe that adherence is not a problem and that once people start treatment they remain on it.

"We have fairly good data showing that once people start they tend to stay on and they tend to take their tablets well. But to start treatment you first need to be tested. Testing rates, especially among men and young people are poor, meaning these groups come in when sick or not at all"

Professor Francois Venter

Other people believe that adherence is a problem. A qualitative study carried out at Alice in the Eastern Cape in South Africa, suggests the need for treatment and counselling facilities to be made more accessible to PLWHA.

The interviewing of just a small number of PLWHA identified a number of themes relating to adherence. These included:

Poverty

Food insecurity was a recurrent theme. Participants frequently mentioned that lack of adequate food actually compromises the effectiveness of the ARV drugs, given the side-effects. One person said:

"There are times when I lack food at home and that makes it difficult to take my treatment on an empty stomach because they could aggrevate your health. Taking ARVs on an empty stomach results in headaches, weak body and diarrhea."

Financial constraints were another important theme that impacted on adherence. Participants pointed to unemployment and living far from the clinic as resulting in some of them missing their medication refill appointments.

"My village is far from town so we struggle to get to the hospital. The transport requires cash. I then end up walking to the hospital.

Violation of Human Rights

Deprivation of Sick Leave Participants reported that their employers refuse to grant them leave to collect their treatment despite knowing their health status. Moreover participants said that their employers had threatened to fire them and employ other people should they be absent from work.

"I am working in the bushes, so sometimes I take my treatment after the scheduled date because the bush manager does not give me a day off and he says that I am not sick"

Unprofessionalism 

Unacceptable attitude and conduct Many participants expressed the view that nurses need to be educated to respect patients' human dignity. They recounted incidents where people who had not adhered to the ARV treatment, for reasons such as relocating to another village, marital conflicts or securing admission for children's education, were ridiculed by nurses and told that they were no longer on the treatment programme.

"The nurse shouted at me in front of other patients after I told her that my reason for not adhering to my treatment was after my husband threw away my pills and beat me"

Discrimination

Derogatory remarks Discrimination had been experienced by some of the participants in the form of rejection by their family members, employers and also community members who would also pass derogatory remarks.

"My family is scared of me and claims that I am going to infect them with this disease, and they do not even want to eat the food that I have cooked. They talk bad things about this disease."

Stigma A female participant said that it had become difficult even to come to the clinic to collect the ARV treatment because some of her spous's colleagues had seen her there and had started to be discriminatory towards her.

"I once defaulted because even my husband was being stigmatized by his colleagues who saw me in the ward meant for HIV/AIDS patients."

Summary

It seems clear that more studies need to be undertaken in other parts of South Africa to establish more about the issue of adherence. If other studies confirm that the matter of adherence is important then urgent steps need to be taken to help people living with HIV to adhere to their treatment.

If this is not done then there will be increasing illness and deaths.

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