There have long been warnings about careful management of ARV rollouts. One of the main worries was about resistant strains of HIV developing in large numbers of people where the treatment program was not being administrated well. Because, while the cost of ARVs is high, the cost of second line ARVs, needed when resistance develops to first line drugs, can be five to ten times higher. But eventually, a lot of resistance will develop because people are not responding to treatment it or are not taking it according to requirements.
However, a related worry is that of transmitted resistance. Those who are not on ARVs can acquire a strain of HIV which is already resistant to first line drugs. A study in Zambia has found that almost 6% of HIV positive people who are in need of treatment are resistant to first line drugs. It's all very well to say the people involved can be treated with second line drugs. But in addition to the massive increase in costs involved, second line drugs are just not as widely available.
The trouble with resistance, whether acquired or developed, is that it will eventually reach high levels. In countries where ARV programs have long been available, resistance can be as high as 20%. Coupled with this, recent WHO guidelines recommend starting ARV treatment at an even earlier stage in disease progression (though some question the wisdom of this). That sounds great but, not only are numbers of people on treatment in African countries very high, health services and health infrastructures are weak, very weak.
Similar circumstances have already given rise to resistant, multi-drug resistant and extensively drug resistant TB. The problem doesn't get resolved by the production of stronger drugs unless the circumstances that gave rise to resistance are also resolved. Many people in Kenya who are HIV positive also have TB. But many who don't have HIV do have TB. 50% of people with TB are not HIV positive. These are two separate epidemics, despite considerable overlaps. Resistance in either TB or HIV treatment will fuel at least one, perhaps two devastating epidemics.
Monitoring and testing for poor adherence to treatment and resistance are expensive. African countries are struggling to implement the most basic treatment services, let alone such advanced facilities. Some of the costs may go down, but unless broad health systems are developed, the lack of adequate facilities, trained personnel and equipment will mean that the majority of people are still vulnerable.
You can't expect weak health services to implement massive, high technology programs. Yet, this is what seems to be expected of African health services. The majority of people have little or no access to primary health care, water and sanitation, adequate food and levels of nutrition, some of the most basic aspects of health. People die of diarrheal conditions and respiratory problems. What chances have they with HIV and TB?
The HIV agenda has been driven by the desire of pharmaceutical companies to sell drugs at the highest price they can get to the largest number of people possible. Not only is resistance, acquired and developed, a consequence of allowing Big Pharma to drive the HIV agenda. Resistance is also an excellent way of increasing their profits further. But what about the epidemics? What about people who are HIV positive and those who are in danger of becoming infected?
If donors, governments and the HIV industry can accept that preventing and treating HIV is not just a matter of distributing ever increasing quantities of drugs, the agenda should include other items, such as the need for more and improved hospitals, more and better trained and motivated personnel, better equipment and supplies. People must be able to access primary health care, not a bunch of kiosks that give out drugs, almost willy-nilly. And good health also requires good infrastructure, education, food security and a whole lot of other things.
It's the job of Big Pharma to sell drugs but it's not the job of UNAIDS, the WHO, national governments, academic institutions and other parties to support them and their excesses. Prevention of further transmission of HIV is getting lost in the process of selling drugs. Some even believe that prevention of HIV transmission will be effected by greater consumption of drugs. This is not the case. Countries that are devastated by epidemics are not just markets; epidemic and endemic diseases will not be eradicated by treating them as commercial opportunities. Use of drugs for HIV treatment must be responsible, which it is not at present.
(For a discussions about pre-exposure prophylaxis (PrEP) and resistance, see my other blog.)