(ARV-) Free State? The moratorium’s threat to patients’ adherence and the development of drug-resistant HIV
In October 2008, the new minister of health announced that 550,000 PLWHs were on ARVs in South Africa, which is the highest number in the world.5 This achievement was recently tarnished by increasing alarm over the Free State public sector ARV programme. The Free State has the third highest HIV prevalence in the country (31%) 6. Since December 2008, the department of health has stopped initiating new patients on ARVs 7 because of drug stock-out and lack of funds. It is estimated that in this province 30 PLWHs are dying every day the moratorium continues.8While it is clear that this moratorium will increase morbidity and mortality, the loss of trust in the health system and the potential impact of the ARVs crisis on existing patient adherence should also be considered.
Campero et.al. reported that patients already on ARVs share their medication with neighbors, relatives and/or friends who are delayed to start on ARVs 9. This practice could lead to drug resistance development in both people sharing the medication if they will have differential exposure to ARVs, 10-13 and on a public health level, raises serious concerns about drug failure, subsequent more expensive drug regimens and the spread of drug resistant strains of HIV.
Patients’ perceptions of staff attitudes and waiting time were reported to be key factors for patients’ ARV adherence. 14 It is plausible that PLWHs will seek care in other provinces, and would consequently be required to return to outlying clinics on a monthly basis to pick-up their ARVs. Transport costs and the time needed to reach clinics are risk factors to both adherence and retention in care.15, 16 Patients currently on treatment – in the Free State and elsewhere - are understandably anxious about the health system’s ability to guarantee life-long access to ARVs.
It was shown estimated that 300 000 people had died of AIDS in a preventable manner if the South African government had only responded to the AIDS crisis quickly in a coherent manner. 17 How the government now contains and repairs the damage being done in the Free State will be a litmus test for the long-term success of South Africa’s ARV programme.
1. Moatti JP, Spire B, Kazatchkine M. Drug resistance and adherence to HIV/AIDS antiretroviral treatment: against a double standard between the north and the south. Aids 2004;18 Suppl 3:S55-61.
2. Check E. Staying the course. Nature 2006;442:617-9.
3. Mills EJ, Nachega JB, Buchan I, et al. Adherence to Antiretroviral Therapy in Sub-Saharan Africa and North America. JAMA 2006;296:679-90.
4. Bangsberg DR, Ware N, Simoni JM. Adherence without access to antiretroviral therapy in sub-Saharan Africa? AIDS 2006;20:140-1.
5. Media room - Departmenf of health - South Africa. Speech by the minister of health Ms. Barbara Hogan at the HIV vaccine research conference (http://www.doh.gov.za/docs/sp/sp1013-f.html). In: Vaccine research conference; 2008; Cape Town Oct.13-16; 2008.
6. Department of Health - Pretoria - South Africa. National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa 2006; 2007.
7. ART crisis - Free State province, Dec. 2008 (http://www.sahivsoc.org). 2009. (Accessed March 18, 2009, at
8. Thom A. 30 dying every day in the Free State - HIV Clinicians (http://www.health-e.org.za/news/article.php?uid=20032192). Health-e 2009 Feb. 19.
9. Campero L, Herrera C, Kendall T, Caballero M. Bridging the gap between antiretroviral access and adherence in Mexico. Qualitative Health Research 2007;17:599-611.
10. Bangsberg DR. Preventing HIV antiretroviral resistance through better monitoring of treatment adherence. JID 2008;197:S272-S8.
11. Bangsberg DR, Acosta EP, Gupta R, et al. Adherence-resistance relationships for protease and non-nucleoside reverse transcriptase inhibitors explained by virological fitness. AIDS 2006;20:223-31.
12. Boulle A, Ford N. Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges? Sex Transm Inf 2007;83:503-5.
13. Gardner EM, Sharma S, Peng G, et al. Differential adherence to combination antiretroviral therapy is associated with virological failure with resistance. AIDS 2008;22:75-82.
14. Dahab M, Charalambous S, Hamilton R, et al. "That is why I stopped the ART": Patients' & providers' perspectives on barriers to and enablers of HIV treatment adherence in a South African workplace programme. BMC Public Health 2008;8:doi:10.1186/471-2458-8-63.
15. Murray LK, Semrau K, McCurley E, et al. Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: a qualitative study. AIDS Care 2009;21:78-86.
16. Tuller DM, Bangsberg DR, Senkungu J, Ware NC, Emenyonu N, Weiser SD. Transportation Costs Impede Sustained Adherence and Access to HAART in a Clinic Population in Southwestern Uganda: A Qualitative Study. AIDS Behav 2009.
17. Chigwedere P, Seage GR, 3rd, Gruskin S, Lee TH, Essex M. Estimating the Lost Benefits of Antiretroviral Drug Use in South Africa. J Acquir Immune Defic Syndr 2008.
Ziad El-Khatib, Division of Global Health (IHCAR);Karolinska Institutet;Stockholm
Marlise Richter, Steve Biko Centre for Bioethics, University of the Witwatersrand, Johannesburg
Full TextPDF (72KB)
Cite this article
Date published: 2009-06-11
Full text views: 1584