What Happens If Antiretroviral Therapy Starts to Fail?

In one of the areas with the highest prevalence of HIV infection in the world (40% of the population in Manhiça), families and communities have been decimated by the epidemicIt's 6.30 in the morning in Mozambique, and the waiting room of the pharmacy in the Manhiça health centre is already packed with people. Queues have formed in front of the window where drugs are dispensed; some people have made the journey overnight and others have travelled many kilometres to arrive early. The crowd includes children who have made the journey on their own and women who have walked all the way carrying a baby, or maybe two, on their backs. The queue moves forward slowly. There is only one pharmacy technician to deal with everyone. Some people leave empty-handed. The medicine they came to collect is not available this week. Little explanation is offered, and they will have to come back next week to take their place in same queue and see whether their luck is any better.  

Today, treatment with antiretroviral drugs offers a more hopeful future. And the message has been heard by the population—hence the queuesThis scene is repeated daily in many hospitals in sub-Saharan Africa.  Most of the people waiting in these interminable queues come to get medication for HIV. Once a month they collect the box containing the pills they have to take every day until the next month comes around. These are the drugs that keep the virus at bay, that prevent the disease from progressing and making them sick, a sequel they have seen many times among relatives, neighbours and friends. Here, everyone has seen someone close to them die from AIDS. In one of the areas with the highest prevalence of HIV infection in the world (40% of the population in Manhiça), families and communities have been decimated by the epidemic. A few years ago, the outlook was bleak. A diagnosis of HIV was a death sentence. Today, treatment with antiretroviral drugs offers a more hopeful future. And the message has been heard by the population—hence the queues.

The problem of resistance to antiretroviral drugs is spreading in AfricaIn a building opposite the pharmacy, there is a maternity ward. One of the patients there, a woman called Aurelia, was diagnosed with HIV four years ago. She takes her tablets every day and comes to the centre regularly for follow-up visits, but recently she has not been able to go home. Three times in the last month she has been hospitalised, and today she is very weak. Aurelia is 12 weeks pregnant. The virus is gaining ground and is replicating despite her treatment.  The disease is progressing, her pregnancy is at risk, and the likelihood that she will transmit the virus to her baby is growing.  The virus has become resistant to the drugs she is taking and Aurelia’s treatment should have been changed some time ago. However, alternative, or second-line, treatments are expensive and are not always available in most health care facilities in Mozambique.   

We have to ensure access in these countries to fast, simplified and affordable tests that can detect whether the antiretroviral treatment is failingThe problem of resistance to antiretroviral drugs is spreading in Africa. It is the flip side of the successful mass distribution of antiretroviral therapy throughout the continent in recent decades. According to the latest figures from UNAIDS, in 2013 some nine million people in developing countries received antiretroviral therapy, a figure ten times higher than in 2003. Many lives have been saved. However, problems with distribution and supply in these countries complicate the supply of drugs for which strict adherence to the prescribed regimen is essential. Resistant strains of the virus take advantage of these fluctuations to become stronger, replicate and spread among the population. If they spread enough, they could threaten everything that has been achieved over years of fighting HIV/AIDS in Africa, the continent where 70% of those affected live.

There is an urgent need to ensure that patients who already have a resistant virus—25% of those being treated in Manhiça—have access to alternative treatmentsIf we monitor HIV levels in patients on antiretroviral therapy on a regular basis, we  know whether the drugs they are taking are working or not. This viral monitoring, something that is done routinely in developing countries, is still not available for many patients with HIV in countries with limited resources. We have to ensure access in these countries to fast, simplified and affordable tests that can detect whether the antiretroviral treatment is failing to prevent the virus from replicating and destroying the patient's defences. Then the patient’s treatment can be switched as soon as a drug stops working and before the HIV becomes resistant to all drugs. There is an urgent need to ensure that patients who already have a resistant virus—25% of those being treated in Manhiça—have access to alternative treatments.

We have to ensure access in these countries to fast, simplified and affordable tests that can detect whether the antiretroviral treatment is failing If we do it right, if we make the right decisions and take the necessary action in time, we can prevent HIV from developing resistance to the drugs, we can stop the spread of the infection from mothers to their babies, and we can stop the progression of the disease in infected people. We have to make sure that people like Aurelia receive the best possible treatment and monitoring. And to do this, we have to invest in public health policies and in research that could change the future of these people and, why not, perhaps even eradicate this disease. 

[This entry has been written by María Rupérez, Denise Naniche (both of them researchers at ISGlobal) and Roger Paredes, main researcher of the Microbial Genomics area at Institut de Recerca de la Sida Irsicaixa. The three of them have co-authored the study Determinants of virological failure and antiretroviral drug resistance in Mozambique.]