Reducing the spread of HIV/Aids with ARV treatment

Estella Kyomugasho, 35, a mother of six tested HIV positive in 2007. Her CD4 cell count was slightly above 500 and health workers advised her to wait until it dropped to 250 as was the policy then. Estella was then given septrin tablets that she would swallow every day until her CD4 count dropped to the level that health workers deemed legible for her to start on anti-retroviral drugs. And to do this, she had to visit the health centre occasionally for easy monitoring of her immune system.

And when her CD4 count finally dropped, she was indeed given her first ARVS a year later. The problem with this method is that the lower the person’s CD4 count, the higher the load of HIV virus in their body hence weakening the body’s ability to produce cells and antibodies to fight the virus.

This situation is not unique to Kyomugasho. Dr Francis Kiweewa, the head of research at the Uganda Joint Clinical Research Centre, says once inside the body, the HIV virus will attack specialised cells of the immune system called T-cells (also called CD4 cells) and while inside the immune cells, the virus will multiply rapidly producing more than a million copies of the virus within a few minutes causing the immune cell to burst open to release the babies of the virus.

“The released virus will attack other immune cells and the cycle will repeat itself more like an ambush on the body’s defences. As this goes on, the immune cells are depleted in numbers while the virus numbers go up unhindered,” Dr Kiweewa explains.

According to the 2011 multi-country research studies by the Global HIV/Aids Prevention Trials Network, the trend of the fast spread of HIV virus could be averted only if all individuals who test HIV positive are started on treatment immediately no matter the CD4 count. Studies on “treatment as prevention” showed that anti-retroviral (ARVs) cut transmission of HIV by 96 per cent within couples where one partner is HIV-positive and the other is not infected. A later study done in South Africa supported the findings.

This means that the ARVS will prevent the virus from multiplying as Dr Alex Ario, the Programmes Manager for HIV/Aids prevention at the Ministry of Health puts it, “You can only give out what you have, and so the more virus one has in his/her body the more efficient he/she is able to share (read transmit) with those one interacts with sexually.”

“What ARVs do is to rapidly reduce the amount of the virus (viral load) in one’s system so that there is little to share with the others. So the principle is to prevent the HIV from multiplying and thereby reducing the amount of the virus in your body by taking ARVs so that you have little or none to transmit,” he explains.

In July 2012, Dr Gottfried Hirnschall, director of the HIV Department at the World Health Organisation, while at the International Aids Conference in Washington DC, said when people take anti-retrovirals, the amount of HIV in their body is decreased, making them much less likely to pass the virus to others.

“If we can get, and keep, more people on treatment, and reduce their virus levels, we can reduce the number of new people who are infected since we now have evidence that the same medicines we use to save lives and keep people healthy can also stop people from transmitting the virus and reduce the chance they will pass it to another person.”

Because of this, the world’s authority on health recommends that anti-retroviral therapy be offered to the HIV-positive person, who has an un-infected partner regardless of the strength of their immune system, to reduce the likelihood of HIV transmission.

Globally, it is estimated that up to 50 per cent of HIV-positive people in on-going relationships are estimated to have HIV-negative partners. Rwanda and Zambia are already implementing this new policy although Uganda remains on the list of the countries that plan to implement this policy despite having a worrying number of discordant couples who are at the risk of contracting HIV.

Contrary to the WHO current recommendation that people diagnosed with HIV start taking ARVs when the strength of their immune system drops to a CD4+ count of 350 cells/mm3 or lower, in Uganda’s situation, treatment is given to people whose CD4 count has dropped to as low as 250.

Dr Ario explains that Uganda is currently not able to provide treatment for infected people whose CD4 count is 350 and above due to lack of funds. Uganda has over 1.2 million living with HIV but only a quarter of those can be enrolled on treatment.

Providing ARVs to people living with HIV who have HIV-negative partners, pregnant women and high risk populations, regardless of their immune status, would increase the number of people eligible for treatment in Uganda from the current estimated 577,000 people with advanced stage of the virus who need treatment to 1.2 million.

This would increase the cost of providing treatment in the short term, but policy makers at the global level predict that the economic benefits of early treatment will substantially offset, and likely exceed, programme costs within 10 years of investment arguing that the economic benefit will be derived from the fact that the workforce is healthier and more productive and that costs of treatment and orphan care are reduced.

Currently, Uganda can only afford treatment for 330,000 HIV patients. This means that the number of those who are not on treatment is twice more than those on treatment, pausing a big risk of increasing transmission. And yet, there is a big possibility of reducing new infections by more than 50 per cent if those already infected can be treated immediately.

Huge cost implication
The HIV/Aids prevention boss further says the cost of treating one adult on first line medicine is about Shs40,000 per month and children at Shs20,000; this implies that one patient would require not less than Shs480,000 per year.

“This is not cheap, although it’s highly subsidised. Uganda as a country spends over $47m (Shs117b) per year to treat the current number of patients (330,000) and putting all the 1.2 million on treatment would definitely overstretch the budget further, which is unaffordable at the moment.” Dr Ario explains. Going by the figure, Uganda would therefore need Shs676b every year to treat all the HIV infected people in the country.

But Dr Kiweewa says while putting everyone who tests positive on ARVs would be the ideal thing to do, he also says that in Uganda the approach is actually not feasible due to a number of issues ranging from not having enough resources, and a very weak health system to an uncoordinated leadership witnessed in the national HIV response and as such, it will remain just another good proposal.

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