Resistance to drugs hampers HIV treatment

International Aids Society president Linda-Gail Bekker (left) and President of the French National Ethics Advisory Committee and conference chairman Jean-Francois Delfraissy. PHOTO | AFP
International Aids Society president Linda-Gail Bekker (left) and President of the French National Ethics Advisory Committee and conference chairman Jean-Francois Delfraissy. PHOTO | AFP 

Resistance to drugs used for treating HIV/Aids has increasingly come under the spotlight given the impact this could have on the progress made in managing the disease.

Experts say there is a big risk in treating and preventing the condition if early and effective action is not taken.

The World Health Organisation (WHO) has called on countries to urgently review their treatment programmes.

Detailed findings in The WHO HIV drug resistance report 2017, based on a national research conducted in several countries, reveal that in six of the 11 countries surveyed in Africa, Asia and Latin America, over 10 per cent of people starting antiretroviral therapy have a strain of HIV that is resistant to some of the most widely used HIV medicines.

The WHO recommends that once the threshold of 10 per cent has been reached, the countries should review their HIV treatment programmes immediately.

“Antimicrobial drug resistance is a growing challenge to global health and sustainable development,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus.

“We need to proactively address the rising levels of resistance to HIV drugs if we are to achieve the global target of ending Aids by 2030.”

Drug resistance develops when people do not adhere to a prescribed treatment plan, often because they do not have consistent access to quality HIV treatment and care.

Individuals with HIV drug resistance will start to be unresponsive to therapy and may also transmit drug-resistant viruses to others. The level of HIV in their blood will increase unless they change to a different treatment regimen, which could be more expensive and in many countries, still harder to obtain.

Of the 36.7 million people living with HIV worldwide, 19.5 million people were accessing antiretroviral therapy in 2016.

The majority of these people are doing well, with treatment proving highly effective in suppressing the HIV virus. But a growing number are experiencing the consequences of drug resistance.

In addition to the report, guidelines and the global action plan on HIV drug resistance that countries should adhere to, the WHO released seven new key guidelines and tools at the 9th International Aids Society Conference on HIV Science in Paris, France last week.

The set of guidelines include a new information note on point-of-care early infant diagnosis ASSAYS (investigative procedure in laboratory, pharmacology) to support timely detection of HIV in children.

It also requires that countries monitor the quality of their treatment programmes and take action as soon as treatment failure is detected.

Countries are also encouraged to prioritise research for children and adolescents to address low treatment and quality care for this group.

New guidelines on advanced HIV infection and rapid initiation of antiretroviral recommends screening, treatment and prophylaxis for major opportunistic infections (such as tuberculosis), and rapid initiation of ART and adherence support for people with advanced HIV.

A new technical update advises countries on what to consider when transitioning to a new treatment regimen, including dolutegravir.

The new report also outlines how countries can provide differentiated, carefully-tailored services for various needs of patients.

The ninth International Aids Society conference on HIV Science last week, in Paris. PHOTO | AFP

The ninth International Aids Society conference on HIV Science last week, in Paris. PHOTO | AFP

“We need to ensure that people who start treatment can stay on effective treatment to prevent the emergence of HIV drug resistance,” said Dr Gottfried Hirnschall, Director of WHO’s HIV Department and Global Hepatitis Program.

“When levels of HIV drug resistance become high we recommend that countries shift to an alternative first-line therapy for those who are starting treatment.”

Speaking at the conference, Dr Hirnschall said increasing HIV drug resistance trends could lead to more infections and even cause deaths.

“We are worried that if nothing is done by the countries, we will lose over 135,000 people and record over 105,000 new infections in the next five years,’’ he said.

Professor Linda Gail Bekker, International Aids Society President, said HIV resistance is a big issue because donor funding for the programme is declining.

She said countries need to move with speed and concentrate on the basic science and research, which are critical in the formulation of new regimens.

Prof Bekker said more new drugs are needed to fight the drug resistance.

She added that tackling HIV drug resistance will require the active involvement of a broad range of partners.

Currently, there is a new five-year Global Action Plan which calls on all countries and partners to join efforts to prevent, monitor and respond to HIV drug resistance and to protect the ongoing progress towards the sustainable development goal of ending the Aids epidemic by 2030.

In addition, WHO has developed new tools to help countries to monitor HIV drug resistance, improve the quality of treatment programmes and transition to new HIV treatments, if needed.

“This new report shows a worrying picture of increasing levels of HIV drug resistance and, if unchecked, it will be a major risk to programme impact,” said Dr Marijke Wijnroks, Interim Executive Director of the Global Fund.

“We strongly recommend implementing WHO recommendations for early warning indicators and HIV drug resistance surveys in every national plan for antiretroviral therapy, and to consider funding them through Global Fund grants,” said Dr Wijnroks.

Countries must work on the recommendations to be safe, said Dr Shannon Hader, Director of Centre of Disease Control’s Division of Global HIV and Tuberculosis at the US Centers for Disease Control and Prevention.

“The new report pulls together key HIV drug resistance survey findings from across the globe that, taken together with other national-level data, confirm we must be forward-thinking in our efforts to combat resistance: scaling up viral load testing, improving the quality of treatment programmes, and transitioning to new drugs like dolutegravir,” she said alongside other speakers during the conference.

Kenya has been introducing new products to boost the fight against HIV/Aids and curb the growing rate of resistance.

Currently, about 1.5 million HIV patients receive ARVs from the government for free, costing the taxpayer an average of Sh20,000 yearly per person.

Recently, the country introduced a generic version of the most advanced drug for the virus. Dolutegravir, manufactured by the Indian pharmaceutical Aurobindo Pharma, will be available free of charge in public hospitals and select private facilities.

Kenya is the first country in Africa to roll out the generic version of the drug and the second after Botswana to launch the drug for routine use. This, researchers say, is a move in the right direction.

The medicine is used as a first-line treatment among patients taking anti-retroviral drugs. It is a small tablet taken daily with two other drugs as it is a combination therapy.

The drug which was in the past two years accessible to patients in the high income countries as the drug of choice because of its cost, will now be available to all in the country.

Researchers have recommended the drug for patients who are resistant to second-line ARVs as well as HIV-positive people who inject drugs.

This is one of the drugs that were recommended by the WHO in 2015 as an alternative first-line treatment for adults and adolescents.

“We want to make HIV drugs accessible to all so that whenever you are tested positive, you are placed on the drugs immediately. We want to give them quality and affordable treatment,’’ said Dr Nduku Kilonzo, National Aids Control Council Director.

Dr Kilonzo noted that when treatment is available and people adhere to the right treatment, cases of high HIV resistance will be reduced.

“With the introduction of new products, I must say that we are headed somewhere ...,’’ she said.

Prof Bekker praised Kenya for doing great to fight the scourge but added that a lot more is expected of the country.

“With the introduction of the drug, we are hopeful that more people are going to get the drug and that the resistance will be something to deal with since they will have consistent access to quality HIV treatment and care,’’ she said.

In March, Kenya rolled out a new drug meant to protect HIV-negative people from contracting the virus.

The drug, known as Pre-exposure Prophylaxis (PrEP) and which can prevent HIV infection by more than 96 per cent, is currently given to those at high risk of contracting the virus before being made accessible to the rest of the population.

The dose is one pill daily for seven days and is meant to build adequate protection before exposure to risk of infection.

“We are simply taking care of the uninfected lot to avoid more infections,” said Dr Kilonzo adding that Kenya has been recording high HIV infections.

The drug has been included in the current HIV prevention methods as the most recent strategic framework.

Dr Hader said overall high rates of viral suppression across three recent national Population-based HIV Impact Assessments showed that present first-line regimens remain largely effective.

However, she said special attention to populations at risk for higher resistance, such as paediatrics, adolescents, pregnant women and key populations, will be critical. “We call on the global community for continued vigilance and responsiveness,” she said.

The results of “STAR-self-testing in Africa” an implementation research effort, together with a new landscape report on rapid diagnostic tests for HIV self-testing, is a plus to many countries. This has also been introduced in Kenya for people who want to know their HIV status in the privacy of their homes, offices or even at community clinics. It is considered a big milestone in the fight against the virus.

The kits will be available in private pharmacies and would cost Sh800 to Sh1,000. Test will be done through oral swab and a blood sample.

The oral kit, known as OraQuick, will require the user to do a 360 swab of the upper and lower gum of the mouth before placing the swab in a reagent, which will give results in 20 minutes.

Those using the blood sample kit known as INSTI, would be required to prick a finger and put the blood in a control kit to read the results. Unlike the oral test, the blood sample test gives the results instantly.

If the test is non-reactive or negative self-test, the user is advised to also seek services that will link them to HIV prevention services such as condoms and male circumcision.

Many Kenyans are still reluctant to go for test because of the spectre of stigmatisation.