Current: Vol. 5, Issue 2 April - June, 2008

HIV CHRONOlOGY: TREATMENT AND CARE
(2nd part of our HIV chronology series)

Dr. Arthur Sekiziyivu

On the 14th of March 2008, Uganda commemorated 25 years since the first case of HIV/AIDS was identified at Kasensero landing site in Rakai District. Through parliamentary resolution, outstanding contributions by key individuals and institutions were recognised. The commemoration also served as a critical reminder to the nation that two and a half decades later,
the problem of HIV/AIDS is still a major threat to national development with no room for complacency. In this issue, we review the progress
made in the area of HIV treatment and care. The earliest community response to HIV/ AIDS was characterised by witchcraft and superstition, with several victims desperately turning to traditional healers and fortune-tellers for solutions. This approach was propelled by the lack of a cure or
effective interventions in hospitals and health centres at the time.
Inadequate knowledge on the disease limited dissemination of information from either government or medical personnel. This created an atmosphere ripe for myth and intrigue.The establishment of a national AIDS Control
Programme (ACP) in 1986, coupled with a multi-sectoral approach to HIV largely restored public trust and confidence in the health care system’s ability to deal with the problem. Rapid advancements in knowledge of the disease led to standardized medical practices. Government initiated a nationwide HIV information campaign on how it was spread and its symptoms.
This resulted in a surge in the number of people interested in knowing their HIV status, thus making voluntary counselling and testing (VCT) a major feature of the national response. With more public awareness, the focus inevitably turned to the need for solutions to prolong and better the quality of life of those infected.

Initially, clinicians largely treated HIV patients by giving them therapies that targeted the various opportunistic infections that they presented with.
There was little available both locally and internationally in terms of interventions that would eradicate or at least reduce the load of the virus in the body. This situation meant that when HIV infected people became symptomatic, they were perpetually unwell and in hospital till their death. HIV infected persons also remained highly infectious for the rest of their lives and infected mothers carried a great risk of transmitting the disease to
their babies.

The late 1980s and early 1990s raised some hope with the discovery of antiretroviral monotherapies like Zidovudine (AZT). AZT Monotherapy
was also used to address mother to child transmission. However, these drugs were costly, had multiple side effects and in some cases a
questionable risk- benefit ratio. The threat of viral mutation and rapid development of drug resistant HIV strains while on mono-therapy further dented the value of this strategy. As a result, the demand for more effective and less toxic drug regimes was more than apparent to both practitioners and patients.
The development of Highly Active AntiRetroviral Therapy (HAART) against HIV in the mid 1990s is considered to be one of the great success stories of modern medicine. This multi-drug combination strategy has transformed HIV/ AIDS from an almost universally fatal and catastrophic illness to a manageable chronic illness.
Another major breakthrough, was the discovery that when Nevirapine was administered as one dose to the mother at the onset of labour and one dose to the child within 72 hours of birth, chances of Mother-to-Child HIV transmission (PMTCT) were cut by between 50 – 90%. This is now a widely used PMTCT strategy, not only in Uganda, but the world over. It has been found to be the only feasible and available option for most developing countries. But this did not take away the challenge of HIV-positive children.

Initially, most ART drugs were not paediatric friendly. There were hardly any syrups, suspensions or low-strength tablets that could be prescribed for children under the age of 12. Pharmacy technicians were often forced to break adult strength tablets into halves, or even quarters in order to dispense ART to children. This of course created problems of dosage, method of administration and adherence. The introduction of paediatric friendly formulations has helped solve this.

In Uganda, antiretroviral therapy was initially the preserve of the rich with
the poor primarily depending on charities to access this treatment. The high
cost meant that very few of those who needed these life long drugs would
be able to start treatment, let alone sustain it. In the last decade, prioritization by government, with support from development partners and multiple international and local advocacy movements such as PEPFAR has seen an exponential rise in the number of people accessing free treatment. The commissioning of a local ARTproducing pharmaceutical industry last year means cheaper ART drugs will be available on the Ugandan market soon. Presently there are over 100,000 people on antiretroviral therapy that is available free of charge at all district hospitals. Mothers are routinely tested and, where necessary, given drugs to prevent transmission to their babies. Though the battle is far from over, we are proud of all we have achieved so far.