The Kenyan government's free antiretroviral (ARV) programme has reached more than 160,000 people in need of the life-prolonging therapy, but experts say unless this momentum is accompanied by an equally aggressive treatment literacy campaign, widespread drug resistance could result.
"The ARV programme has not been well-matched with [a] crucial treatment literacy campaign," said Ken Odumbe, ActionAid Kenya's HIV coordinator for Western and Nyanza provinces, which have been hit hard by the pandemic. "The situation is more critical in western Kenya, where the poverty index is 65 percent, which has triggered high levels of non-adherence to treatment because of poor nutrition and access to correct information."
The antiretroviral therapy programme officer in the Ministry of Health, Dr Lyndon Marani, told IRIN/PlusNews that about two percent of the estimated 160,000 people on free ARVs had developed resistance and although these numbers were relatively low, the threat of large-scale drug resistance was "real and scary".
Odumbe said treatment literacy was not only low among patients, but also among health workers. "Resistance is building up because staff in most hospitals in the country show evidence of low treatment literacy."
A survey in 2005 by the Population Council an international non-profit organisation working to improve reproductive health, found that only 33 percent of doctors had been trained in HIV care and management; doctors, clinical officers and nurses, on average, had read only four of the eight national HIV/AIDS guidelines that are required reading.
Resistance to nevirapine, an ARV administered to HIV-positive pregnant women to prevent transmission of the virus to their unborn babies, had already been detected, Odumbe said, and many women failed to respond to treatment after they developed resistance to nevirapine.
"The problem may not be serious at the moment, but the threat is real," said Marita Barasa, a senior counsellor at Women Fighting AIDS in Kenya, a local non-governmental organisation. "We are concerned about the competence of the available manpower to cope with drug resistance."
Ineffective testing mechanisms
Barasa also faulted the criteria used to determine when a patient should be put on ARVs, saying this hampered effective management of HIV.
"The CD4 count test [which measures the strength of the immune system] is misleading, as it does not provide accurate information about the viral load [the level of virus in the bloodstream], which could precipitate serious drug resistance of specific HIV strains," she said.
Kenya's Aga Khan University Hospital has also called on the government to mainstream drug resistance testing prior to the start of anti-HIV therapy.
However, the ministry's Marani said that at between US$500 and $600 per test, the alternative of using drug resistance testing was too expensive for most Kenyans.
"We shall still depend on statistical conclusions to determine the level of resistance," he said. "At the moment we are planning to scale up second-line treatment to keep a lid on the looming ARV drug resistance threat."
Although viral-load tests are supposed to be free at government health facilities, government laboratories outside the capital, Nairobi, still charge $25 per test. CD-4 tests are free, but many rural health centres do not provide them.