HIV Drug Resistance is a Consequence of Irresponsible Drug Use

The availability of antiretroviral drugs (ARV) for HIV treatment, especially in high prevalence countries, has been welcomed by many, and rightly so. Only an estimated one third of people who need treatment are currently receiving it in Kenya and accurate figures about how many people are being successfully treated are probably not available. But the situation is a lot better that it was in the early 2000s, when drugs were still unaffordable (to donors, they will probably always be unaffordable to most Africans) and only a few thousand people were able to access them.

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.

Even in countries with relatively well established treatment programs, drugs of all description are in short supply. Uganda is now depending on emergency funding just to supply existing patients with ARV drugs, let alone dealing with new patients or ones who are affected by resistance. Taking the drugs in accordance with requirements can be impossible for many people.

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.)

Measurement of Success is the Measure of Our Failure

Out of the top ten killer diseases listed by AlertNet, most relate to a lack of something very basic:

Number one, lower respiratory infections are closely related to poor environmental and living conditions; 2, HIV/AIDS is related to many things, including healthcare, education, infrastructure, labor practices, legal issues, equality and others; 3, malaria is to a large extent related to environment and living conditions; 4, diarrhea is mostly related to poor water and sanitation; 5, TB, environment and living conditions.

It's not until you get to numbers 6 to 9, measles, whooping cough, tetanus and meningitis that you find diseases that are generally controlled with a vaccine. And controlling these diseases still requires adequate health systems, education and infrastructure. Number 10, syphilis, can also be controlled by good sexual healthcare, sex education and drugs.

But the point is that medical treatment is not health. Medical treatment is for people who are sick. In order to avoid numbers one to five, the majority of people need things like good housing and domestic facilities, water and sanitation, access to nutritious food, education and the protection of the law against discrimination, exploitation and inequality. If these basic needs are not met, medical treatment alone is unlikely to be of any use. These top ten killers kill millions of people because of the absence of things other than medical treatment and supplying endless amounts of medicine will not prevent illness and death.

The AlertNet article is perverse in that it doesn't mention that the biggest killer, lower respiratory infections, are spread by poor living conditions and that, therefore, deaths could be significantly reduced by concentrating on improving these conditions. One of the Millennium Development Goals includes reduction in child mortality as an indicator of progress. But that doesn't necessarily translate into improving living conditions. Children are especially susceptible to respiratory infections and much of the mortality from these causes occurs in children and infants. But providing lots of treatment is not a substitute for better conditions.

Similar remarks apply to malaria. It can be better controlled if people live in decent housing. When they live in villages, towns and cities, especially, the environment also needs to be such that malaria carrying mosquitoes can be controlled. But a large percentage of people live in semi-permanent housing that doesn't protect them from mosquitoes and other threats. Mosquito nets are good if people have enough space and enough beds to make them effective, yet many live in cramped conditions where mosquito nets are less effective. Technical solutions need the right conditions and have sometimes proven to be a waste of money.

One often hears calls for vaccines against diarrheal diseases and big donors are especially fond of such vaccines.  But what these big funders don't seem to want to ask is why are people drinking water contaminated with their own feces? These vaccines may have some impact at first, but if people don't have access to clean water and good sanitation, they will continue to be infected with other water borne diseases. Is it even logical to give some medicine to people who then continue to drink contaminated water? Vaccines may be a good supplement to eradicating some of the big killer diseases but without ensuring safe water and sanitation, they will have little effect. The same applies to pneumonia vaccines.

Providing people with decent living conditions, water and sanitation and the like are expensive. But billions of dollars are spent on vaccines, much of the money going to rich and powerful multinationals. There isn't a lack of money, just a lack of equity. Most of the money is being spent on subsidizing the rich; pharmaceutical giants, agriculture and the like. It's true that most people in developing countries don't die for lack of food, and malnutrition doesn't usually kill people either. But these both leave people weaker, more susceptible to disease and more likely to die of preventable and treatable diseases.

Sometimes it appears that development misses the point: yes, people are poor, undereducated, unhealthy, isolated and otherwise deprived. But a handful of indicators is not a measurement of development. The aim of development is not to produce a few Olympic runners, jumpers and throwers and then claim some gold medals. The aim is that everyone can enjoy healthy and fulfilled lives. Achieving some goal such as immunizing all (or most, or 80%) of children against a couple of waterborne diseases is a failure if they still die from some other waterborne disease; it's a failure if they don't have access to clean water and good sanitation. Immunization, like much medication, can be a necessary condition to ensure health, but it is not sufficient.

Of course, development experts are not advocating that everyone be supplied with medication and ignoring other conditions. But the money is mainly going towards the technical solutions and not going towards supplying basic needs. In developing countries, many people spend more money on healthcare and health care products than they do on more basic things. And where they don't have the money to spend, a lot of development money is spent on these services and products. Basic needs are prior, in the sense that they must be supplied first. In highlighting how basic some of the top ten killer diseases are, AlertNet takes the first step towards refocusing attention. But it fails to say why so many people in developing countries are dying needlessly or what can be done about it.

Hate the Sinner, Love the Sin

Recently, a Kenyan friend of mine posted a question on Facebook the jist of which was 'if a promiscuous woman is called a whore, what is a promiscuous man called'? She got some facetious replies but it is a very important question. Why do we vilify women who sleep with men? There are many words for women seen as promiscuous but I can't think of any for men. There must be a lot of men who love sex but there must also be a lot who hate women. Could it really be common for men who love sex to also hate women? It seems likely.

A workshop in South Africa recently argued that "society's expectations and presentation of women makes them more vulnerable to catching sexually transmitted infections (STIs) and HIV". There appears to be a deficit of respect built into societies, languages and behaviours and it seems so self defeating. The workshop pointed to "the need for woman and girls to be empowered for them to make informed decisions when negotiating safe sex".

We (humanity) are facing a dangerous situation and it seems that several decades of HIV/AIDS has done little to change attitudes. Men are very often in a position to do things and talk about things that women are not able to do and talk about without censure. Men often say that there are things they find it difficult to talk about and they would never talk about them in front of women. Women, too, are expected to remain silent about certain things and to only discuss others with other women.

I have talked to people who run HIV prevention programmes and they often mention how the content needs to be different when the audience is young or female. It's true that the content needs to be produced with a particular audience in mind. But maybe there is also a place for discussion between males and females. Perhaps it would be enlightening if men were to get to know what women think and if women were to get to know what men think, especially what men think about women and sex, for example.

Why is it more shocking to hear a woman swear or to see a woman drinking or spending time in a bar or, god forbid, time in a bar with men? Men go to bars to hang out with their friends, to drink and to meet women. If they think the women they meet in bars are 'whores', why don't they stop going to the bars and go to church halls instead? Or perhaps they could persuade their 'nice' female friends to go to the bar with them. But that would take us back to square one because women who go to bars are just not nice, apparently.

The workshops also argued that “[i]n the rural set up mostly, women who [negotiate] for safe sex are viewed as promiscuous and wayward”. It's sensible for anyone to insist on safe sex, whether they are male or female. There is something wrong already if the woman has to negotiate. The fact that she is considered promiscuous or wayward is almost laughable, especially considering the reasons why she might feel the need to negotiate; perhaps she knows that a lot of men are happy to have sex without a condom.

People here, male and female, often tell me that women are not supposed to be forward, they are not supposed to make the first move. Men see women who ignore this code of conduct as objects of suspicion and even as in some way evil. Is there something inherently about men that makes them better at making decisions that relate to friendship and sexual relationships? I don’t think so, but perhaps I’m just lacking in some way.

When it comes to negotiating about or even discussing sex, there is a need for greater levels of mutual respect and equality. People are people, gender is not a species. This needs to start in classrooms and among young people. So, if people object to teaching children about sex and safe sex, the least they could do is teach about equality and respect.

A person who has sex with other people is just a person. A person who has sex with lots of other people is also just a person, though they need to exercise a lot of care, as do the people they sleep with. But a sizeable majority of women who have sex, do so with men. It’s not as if there is a small group (or large group) of people who, in some way, are responsible for all the illicit sex in the world.

Quite frankly, if I was a woman, I would be called a whore. I go to bars, I meet women, I’ve even had the temerity to sleep with some women. But as a man, calling me a whore just doesn’t have the same import. And I don’t think the solution is to find an equivalent term for men to right the balance. I think it would be preferable to see sex as something that occurs between people, male and female.

Calling the (Self) Righteous

Recent research shows that HIV attacks normal, healthy genital tissue in women. Previously, it was thought that skin had to be broken or damaged to be infected. No doubt, breaks in tissue or other damage may increase the risk of infection. But it seems that even healthy women are far more vulnerable to HIV than previously thought.

The researchers conclude that treatments such as vaccine are needed. But they also conclude that condoms are clearly needed as they protect against infection. Those favouring the 'ABC' (Abstain, Be faithful, use a Condom) approach to HIV prevention must take note that abstaining and even being faithful are not enough. Many monogamous women are infected by their husbands or by their partner. Yet some people involved in HIV prevention insist that abstinence on its own or abstinence combined with faithfulness are enough.

Abstinence on its own, or even abstinence plus being faithful (where abstinence alone is not possible), are not enough to protect people from HIV. Abstinence is just not an option in many circumstances and being faithful can also be elusive. Abstinence, faithfulness and using condoms are only three aspects of avoiding HIV, other sexually transmitted infections (STIs) and unwanted pregnancies.

Those working in HIV prevention who are squeamish or downright bloody-minded about the use of condoms need to reconsider their stance. Are they interested in preventing HIV or are they merely interested in prognosticating at the expense of the people whose interests they claim to be protecting? People have sex. They may 'abstain' or refuse to have sex or avoid having sex under certain circumstances. But when they have sex, and most people do sooner or later, they need to know what the dangers are and how to protect themselves.

Those who are forced to resort to commercial sex work will need to be particularly careful, of course. But they will also need the protection of the law against violence, rape and other forms of abuse. They will need access to information, to health care and to legal services. These are not readily available to commercial sex workers at present.

Indeed, they are not readily available to the majority of Kenyans. ABC is not enough to protect most people from HIV and other sexually transmitted infections. It never was enough and it never will be enough. When will the moral crusaders realise that they are wrong and that they are creating and upholding the conditions that allow HIV to spread in Kenya and other countries?

Some argue that ABC and other campaigns are suitable for adults but not for children. I would argue that such campaigns are not enough for adults but also that children are even more vulnerable than adults. Therefore children need, not just more strategies and education, but more protection.

Children themselves, when asked, say they feel they are being denied access to knowledge about how to protect themselves from HIV. Under the UN Declaration of Commitment on HIV/AIDS, 2001, children are those below the age of 15. Most young people over the age of 15 don't even receive the vital information they need but the ones who are not targeted, those under 15, are exceptionally vulnerable.

Many of them are already sexually active, often having sexual experiences that they do not choose to have. In other words, they are being coerced or somehow pressurised into having sex. It seems unlikely that those forcing minors to have sex are taking precautions against HIV. So what chance have those minors?

Questions about how to inform children about sexuality and the dangers involved are difficult and may take some time to resolve. But they won't be resolved by pretending that it is unnecessary to even discuss sex and sexuality with them. The belief that children who are informed about sex are more likely to have sex has long been discredited.

Children who are informed about sex are more likely to put off having sex for the first time till later in life, often till they have finished school. They are more likely to understand risks, for example, the risks involved in sleeping with men who are older than them. They are more likely to know about and use condoms. They are more likely to be able to negotiate safer sex.

Perhaps it's not children who have a problem with knowledge of sex and sexuality, perhaps it's adults; parents, guardians and teachers. This problem is not confined to developing countries. Where I grew up, Ireland, teachers and parents alike had problems talking about sexuality. I suspect that many still do. Having spent much of my adult life in the UK, I know that most people there find sex and sexuality difficult to talk about.

That's a problem that needs to be faced, not denied and avoided. The sooner we, as adults, sort out our problems with the subject, the sooner we can protect our own children and young people.

On the subject of moral crusades and righteous indignation, the Kenyan HIV and AIDS Prevention and Control Act, 2006, worries many people. For many years, those involved in HIV prevention and the care of those infected with HIV have been fighting to reduce stigma. This act may increase stigma. If people are to be encouraged to know their status, which is said to be the first step in reducing the spread of HIV, they need to know that they will not be discriminated against in any way if they happen to be HIV positive.

Once everyone knows about the dangers of HIV, once everyone has access to HIV testing and HIV care, once the health and welfare of Kenyans are adequately accounted for, then the question of willful transmission can perhaps be addressed more equitably. But we are nowhere near that stage yet. It would be a mistake to put any obstacles in the way of wider testing and greater openness.

More women than men are infected with HIV, but also, more women know their HIV status than men. Already, women have been the victims of stigma and discrimination, despite the fact that they are not more responsible than men for the spread of HIV. How will this law affect women, who are usually tested when they are pregnant, and those who are willing to be tested? Whoever the law is designed to protect, it seems likely to fail.

Reducing transmission of HIV requires that the rights and responsibilities of everyone be upheld, not just the rights of those who are uninfected. The fight against HIV will necessarily involve those who are infected, just as much as those who are not infected. If their rights had been upheld in the first place they would not now be HIV positive.

Don't exclude HIV positive people, children or anyone else from the prevention equation.