Hope for children who are failing treatment

ASHLEIGH FURLONG writes: A recent programme conducted in Khayelitsha on children and adolescents who were failing ARV treatment  showed that most patients were able to suppress their high viral load within six months through continued adherence support. 

Viral load refers to how much HIV is in one’s blood. A high viral load means that one is more infectious. Treatment failure is when ARVs are unable to contain the HIV infection.

The results were particularly positive for children and adolescents on a protease inhibitor regime, which is a type of HIV drug.

These results were presented at the South African National AIDS Conference being held this week in Durban.

Dr Jonathan Bernheimer, from Medecins Sans Frontieres (MSF) in Khayelitsha and the Southern Africa Medical Unit (SAMU), found that 81% of patients achieved viral load suppression (which is when the virus is undetectable in the bloodstream) at least once during the intervention.

The intervention included clinical care; adherence support such as counselling and support groups and changes of ARVs when needed.

Patients at first had to complete visits every two weeks and then monthly. To be discharged from the study, patients needed to have two consecutive viral load tests which showed suppression. These viral load tests were done every three months.

“For a long time it was thought that it took a long time for paediatric patients to suppress their viral loads.  [however] we found differing data,” said Bernheimer.

174 children from newborns to 19-year-olds were enrolled in the intervention. All the patients had high viral loads and were failing treatment. 173 of the patients were infected at birth.

Bernheimer said that “the vast majority of treatment failure is caused by poor adherence”. He said that the second biggest cause is probably resistance, where the virus circulating in someone’s body mutates to be able to evade the drug. Resistance can occur when a patient does not take their medication as prescribed.

As for the causes of poor adherence, Bernheimer said there are a “ton of them” that can be both patient related and system related. Some examples that Bernheimer gave for patient related causes are whether or not the caregiver is at home, transport issues and stigma.

The system related reasons include health care facilities running out of drugs or patients being unable to tolerate certain drugs.  “Put all those together and you get a get whole bunch of reasons why children are not adherent to medication,” he said.

For example, in the Western Cape, migration can affect adherence, said Bernheimer. “If a child goes to stay with someone else who doesn’t even know they are HIV positive, the child is not going to get his or her drugs,” he said.

During the intervention, at least one instance of viral load suppression was seen for nearly 90% of those aged 0-10, among 10 to 19 year olds, it occurred in only 74% of 10 to 19-year-olds.

Bernheimer also looked at the overall viral load rebound rate. This is when the ARV stops working and the HIV starts replicating again, becoming detectable in the bloodstream. 18% of patients experienced this. Again the results were higher (22%) in 10-19 year olds, compared to 0-10 year olds (14%).

Bernheimer also compared patients enrolled on two different regimes – those taking protease inhibitors (PI) and those taking Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTI). Those on PIs took a shorter time to suppress their viral load and a slightly longer time to have their viral load rebound after their first suppression.

In addition, he found that the vast majority of those failing on NNRTI regimen will require a switch to the PI regimes.