Free ARVs should not be restricted to treatment-naïve, say Ugandan doctors

A group of Ugandan doctors closely involved with their country’s efforts to scale up antirertroviral treatment say that national treatment programmes should not discriminate against people who have been using their own money to buy antiretrovirals (ARVs) when it comes to enrolling future patients.

They say that thousands could be in danger of being refused treatment if they run out of money to pay for ARVs, if national treatment programmes restrict free treatment to those who have never taken ARVs before – the `treatment-naïve`.

“There are serious problems with this restricted access strategy,” say the authors, who are based at the Infectious Diseases Institute at Makerere University in Kampala.

In particular, patients may not reveal that they have received previous treatment if they know that only the treatment-naïve will qualify. This could result in the selection of drugs that will increase resistance.

Programmes may also be slower to enrol, and the authors comment that patients already taking ARVs and known to be adherent to their regimen could be enrolled quickly, with less effort.

“Most of these patients have made great sacrifices to access ARV treatment. They have kept appointments at the clinic, and they have been adherent to their treatment regimen as long as money was found to purchase ARVs. In contrast, other individuals may have delayed being tested for HIV, while continuing risk behaviour, and only accepted HIV testing because of the promise of free treatment. Many of them have not been as ill as those who have managed to somehow find resources to initiate treatment.”

Although some patients with prior treatment experience have been enrolled onto Uganda’s national programme, resources are not available to roll all paying patients over to free treatment, and the authors argue that sooner or later many will run into problems because they cannot afford further medication. They point to studies from Senegal, Kenya, Botswana, Nigeria, Cote D’Ivoire and Uganda showing that user fees have an adverse effect on treatment adherence.

The opinion article is of particular relevance to returned asylum-seekers who have been refused leave to remain in the United Kingdom. Home Office lawyers are increasingly arguing that with free treatment available in many African countries, individuals can be discontinued from a course of treatment in the United Kingdom and returned to their country of origin without any susbtantial interruption to their treatment.