Physicians in the UK who prescribe HAART to Africans should not assume that their patients are naïve to antiretrovirals, caution doctors from Portsmouth writing in the November 7th edition of AIDS (now available online).
The Portsmouth doctors describe the case of a 40 year old Zimbabwean man who was found to have extensive resistance to antiretroviral drugs. The case report also reveals an example of presumptive treatment of HIV without HIV testing in Africa, raising questions about how widespread this practice might be.
In March 2002 the man, who had been in the UK for one week, attended the gentiourinary medicine department at St Mary’s Hospital, Portsmouth and requested an HIV test. He reported a six-month history of night sweats, rashes, and extreme tiredness. Tests confirmed that the man was HIV-positive, with an advanced degree of immunosuppression, his CD4 count being 30 cells/mm3 and HIV viral load 110,000 copies/mL.
The patient was not surprised by the positive result and told doctors that although he had not previously been tested for HIV, he had had a low CD4 cell count in Zimbabwe. He also told doctors that he had received treatment with antiretroviral drugs comprising Combivir for one month immediately followed by indinavir, d4T and ddI for the four months prior to his arrival in the UK.
Resistance tests revealed multiple NRTI and protease resistance mutations. He was started on a HAART regimen of tenofivr, lopinavir, ddI and nevirapine.
This led to an improvement in the man’s symptoms and a fall in his viral load to 2,110 copies/mL and an increase in his CD4 cell count to 300 cells/mm3. Although the man reported good adherence his viral load never fell below 50 copies/mL prompting the investigators to conduct a further resistance test that established that the man had developed additional resistance-conferring mutations to both NNRTIs and protease inhibitors. However, whilst waiting for the results of these tests, the man’s visa expired and he returned to Africa.
Commenting on this case, the man’s doctors note, “as a result of previous inadequate and intermittent therapy, this man unexpectedly developed widespread HAART resistance that is more typical of a patient who had received ART over many years.”
They add that doctors proving HIV treatment to HIV-positive Africans should not assume that these individuals are antiretroviral naïve. Programmes are starting to provide supported and structured access to HAART. However, individuals are also getting anti-HIV drugs from pharmacies, private practices and family and friends. In these circumstances individuals may not be given information on how to take treatments properly, and receive little or no monitoring of adherence or the success of therapy.
Patients from southern Africa may, therefore, “have been taking sub-optimal and intermittent therapy, depending on treatment availability and financial constraints.” Once in a country that provides HAART they may be reluctant to admit previous antiretroviral therapy due to fear or lack of understanding of the significance of previous anti-HIV drug exposure.
The Portsmouth doctors also caution that the use of suboptimal therapies and unstructured use of HAART could mean that by the time that HAART becomes widely available in Africa, many patients may already be highly resistant to anti-HIV drugs and difficult to treat.
Further information on this website
Resistance - booklet in the information for HIV-positive people series
Foley E et al. Extensive antiretroviral therapy resistance in an HIV-infected Zimbabwean patient in the UK. AIDS 17: 2404- 2405, 2003.