Sunday, January 29, 2023

Botswana’s gains in fight against HIV/AIDS threatened by lack of strategy to manage drug resistance

Botswana’s hard won success in the fight against HIV/AIDS is in danger of being reversed by the dearth of a comprehensive strategy to combat drug resistance among infected patients – it has emerged.

With the world’s fourth largest prevalence of HIV infections, Botswana is exposed to one of the world’s biggest threats to HIV/AIDS drug resistance.

As the world concluded its commemoration of the 2022 World Antimicrobial Awareness Week last Thursday, it however became apparent that Botswana is one of very few African countries that do not have an antimicrobial resistance national action plan. Worse still, the country does not have an idea about the extent of its drug resistance threat.

Antimicrobial resistance, commonly known as “drug resistance”, occurs when disease-causing germs become resistant to traditional medication, making infections harder to treat and increasing the risk of disease spread, severe illness and death.

Speaking at the 2022 World Antimicrobial Awareness Week Dr Nonhlanhla Dlamini, the deputy country representative of the World Health Organization to Ethiopia warned that antimicrobial resistance was putting at risk decades of progress made in the control of HIV/AIDS, tuberculosis, malaria and sexually transmitted infections.

Dlamini was reiterating the concern expressed earlier last week by WHO Regional Director for Africa Dr Matshediso Moeti who called on African countries to invest in sustainable local financing and implementation of the antimicrobial resistance national action plans focused on infection prevention and control. And how does Botswana stack up against such warning:

Research published in the United States National Library of Medicine in August found while many countries in Sub-Saharan Africa have developed national action plans, some countries like Botswana and Namibia are yet to officially launch their own.

The research found South Africa has made the greatest strides with implementing its national action plans, including regular monitoring of activities and instigation of antimicrobial stewardship programs.

Another research report by  Principal Investigator and Research Associate at Botswana Harvard AIDS Institute Partnership Simani Gaseitsiwe in conjunction with, Sub-Saharan African Network for TB/HIV Research Excellence (SANTHE) which was published in September this year found that Botswana does not have an idea about the extent of its drug resistance threat.

It emerges from the research report that in Botswana, screening for HIV drug resistant variants is done only when patients who are on treatment have high viral loads – over 1,000 copies/ml, as per the World Health Organization guidelines. “This means drug resistant HIV variants in patients with low viral loads aren’t detected.”

The research report further states that, “ “We found that people with low viral loads were just as likely to harbour drug resistant HIV variants as people with high viral loads….. We recommend that patients on ART with detectable viral loads above 50 copies/ml be further investigated to ensure that they don’t harbour drug resistant HIV variants.”

The report further states: “ Our study looked at a cohort of 6,078 people with HIV from across Botswana who were receiving combination antiretroviral therapy. We narrowed this down to 4,443 people who had been on ART treatment for at least six months.

Only 8% had viral loads of more than 50 copies/ml. Testing for mutations only happens on patients with viral loads of over 1,000 copies/ml, which means that this group isn’t being screened.

The figure of 8% may seem low. But it means that this cohort either has a resistant variant, or their treatment isn’t working.

“Prevalence of drug resistant mutations: We sequenced the HIV in the patients with low viral loads as well as those with viral loads above 1,000 copies/ml. We found no difference in the prevalence of HIV drug resistant mutations between the two patient groups. This indicates that patients with low HIV viral loads are just as likely to harbour HIV variants with drug resistance mutations as those with high viral loads.

Treatment failure: A select group of the patients with low HIV viral loads were followed up for at least a year. We found that there was a statistically significant association of low level HIV viral load with subsequent virological (or treatment) failure. Our results show that patients with a low HIV viral load are more likely to experience virological failure.

Current treatment guidelines describe virologic failure as viral loads above 1,000 copies/ml. Our results challenge this.”

The researchers stated that our results echo the views expressed by others who have looked at this issue. Like them, we recommend that the HIV treatment guidelines in developing countries be improved to ensure that patients with low HIV viral load while on ART get the necessary attention.

In developed countries, screening for drug resistant HIV variants is done when people start ART. Drug resistance screening is also done whenever a patient on treatment has a detectable viral load.”

The same approach should be applied in developing countries like Botswana.

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