• ‘Inaccessibility to third line ARV drugs threatens Nigeria’s HIV treatment response’
By Sola Ogundipe
Worried about gaps in the National HIV/AIDS treatment plan, Deputy Director of Research and Head, Clinical Sciences at the Nigeria Institute of Medical Research, NIMR, Yaba, Lagos, Dr. Oliver Ezechi, has raised the alarm over imminent increase in AIDS-related deaths in the country.
He expresses concerns over treatment failure and emergence of drug resistant HIV strains, noting that HIV patients that are experiencing resistance to first and second line anti-retroviral (ARV) drugs are unable to afford life-saving third line drugs that cost N80,000 per course of therapy monthly.
Urging the Federal Government to urgently address the situation, Ezechi warns that continued inaccessibility, unaffordability and unavailability of the third line drugs will fuel HIV transmission and re-infection. Excerpts:
National HIV treatment status
Our HIV/AIDS treatment has matured and we now have people who have failed first line drug treatment, failed second line drug treatment and are now on the third line of treatment. And we know that as your treatment matures, when you start people on treatment, a percentage will not comply or adhere; it’s a natural occurrence. It has been proven that about 10 percent of those on the first line will fail and move on to the second line and another 10 percent will likely fail and move to third line treatment. So what we have is that about 10 percent who started on the first line are now on third line drugs which are not available in the hospitals. They have to buy these third line drugs out of pocket, and they are quite expensive.
What I mean by failure of treatment is that the drugs would no longer work for some people. This is because of the nature of the virus which mutates and divides rapidly and once this happens, it produces some forms that the drugs would no longer recognise. We know from science that 10 percent of any group on first line treatment even with good adherence will fail. However, when people are not adhering very well, the percentage will increase. So what we are saying is that in the best of the situation that adherence is good, drugs are working, 10 percent will fail. What it means therefore is, when we are making provision for first line drugs, we should also make provision for second and third line drugs.
Paucity of funds
And as you get into your programme development, over a period of time, people would definitely fail first line to second line and when they are on the second line for a long time, will drop to third line. Presently, within the National programme, third line drug is not available. Government has not yet begun budgeting for third line drugs. The issue is the PEPFAR programme did not have provision for third line drugs and since close to 30-40 percent of our programmes are donor driven, the counterpart is supposed to be provided by the government. For now, those funds are not available.
No third line drugs
For now in NIMR, we have about 50 people as those to be on the third line of treatment, but the drugs are not available and they cannot afford its cost in commercial pharmacies at about N80,000 per month.
How many people can afford N80,000 a month? Invariably, many are already on single dose therapy and we all know single therapy in HIV treatment is not allowed. Previously, people were used to buying 1st line drugs but now are forced to buy the third line drugs due to its non-availablity in our hospitals. So, we are calling on government to please make provision for third line drugs.
More AIDS-related deaths imminent
In the theme of the 2017 World AIDS Day, we are indeed leaving some people behind. If we don’t want to leave anyone behind, as we are budgeting for first and second line drugs, we should also budget for 3rd line drugs. The overall effect of those who are on 3rd line drug treatment who cannot afford to purchase it, is that there will be more deaths of people with AIDS and those people who are already on 3rd line drugs but cannot get the drugs will fuel transmission and re-infection in the society.
We have been talking about removing HIV from Society with 90 percent treatment, 90 percent suppression of virus. But with the current situation we are not likely to achieve that. While other countries might be heading towards eliminating HIV, it might still remain with us.
As our programme gets mature, we are beginning to have adolescents on the 3rd line of drug treatment. Remember those children who were born with HIV were started on HIV drugs and have remained alive and most of them are now adolescents transitioning into adults. We know once they transition into adults, we lose them because the programme does not capture them separately.
In the programme, once they are 15, they are categorized as adults but in the real sense of it, a 15-year-old is not an adult. Imagine a 15-year-old sitting with adult in HIV clinic, that person will not feel comfortable.
Need for adolescent clinics
For us at NIMR, we have an adolescent clinic which runs 2nd Saturday of the month. We already planned for that group’s transition but this is not obtainable elsewhere. We really need to translate this into all the levels of care. We need to start having adolescent clinics. At NIMR our adolescent clinic is almost like a Club and quite friendly as adolescents don’t want to to come to where they won’t be free.
The issue is that some of these decisions are government-based. How many government workers want to go to work on Saturdays just to attend to a group of people?
For our staff, it is a big sacrifice because we understand adolescents need to go to school during the week and the staffs are interested to use their time. Now imagine when this group of people retires or is no longer in service, what will happen? So, government would have to find a way to sustain adolescent clinics and have adolescent –friendly clinic environment.
It is time all state governments began to understand that once they provide drugs for children born with HIV, they will grow into adolescents and there will be need to plan for their lives as adults. Those who were born in 2000 are now 17 years, we need to plan for them.
Separate treatment for adults and children
We should stop verticalising programes. We should not put children and adults in the same clinic. Yes, people are talking about family centered clinics, because we do not want mother to come separately with father and come again with children three times a week. This can still be achieved with segmentation of clinics but for the adolescents, you cannot lump them together. Though they ae not adults yet they want to feel like adults, a separate Saturday clinic is good enough for them so they are alone. Everyone still moralises that HIV is predominantly through sexual transmission but we know for most of these adolescents it is through mother-to-child so it is not fair to moralise their situation.
For the 3rd line drugs that aren’t available at the hospitals, patients still need to order from pharmacies who in turn order for them overseas on their behalf and it could take up to a week or two for the drugs to arrive. So what we do at the moment is to sequence drugs for the patients who have failed both 1st and 2nd lines of treatment. We mix drugs for them though with the knowledge it is not the best in the circumstances. But rather than watch them die slowly, we try to help them manage living