The spread of drug-resistant HIV in South Africa is at a point where about one in five adults and one in two infants that become infected will be resistant to one class of drugs used in the HIV treatment plan. Not taking treatment diligently can also cause people to develop multidrug-resistant HIV. Drug-resistant HIV complicates current treatment plans and means there are less drug options for these patients. On top of this, there are social and economic constructs fuelling the spread of drug-resistant HIV. While I believe we can always find ways to treat HIV, no matter how big the problem, we are at a point where current treatment options have become more limited.

Mutation

HIV is a complex, potent disease and when it mutates, it produces different variations of itself. This can lead to the development of multiple drug-resistant strains in the person’s body. Drugs that previously targeted a person’s HIV fail to fight these new strains, which means they cannot prevent the new strains from multiplying.

Drug resistance develops if a patient does not take their daily dose of medication. This gives the virus opportunity to mutate in the presence of the medication. Over time, this line of treatment becomes ineffective and fails and the drug resistant virus becomes the dominant virus in the body. There are tests to see if patients have this drug resistant virus, but as the country with the highest infection rate in the world, and the cheapest test costing about R2000, this test is reserved for patients failing second-line treatment in the public health sector.

This doesn’t just complicate the treatment plan for the individual patient, it presents a scary reality when it comes to transmission because this drug-resistant virus can also be passed onto drug users sharing needles, as well as sexual partners or from a mother to her child during pregnancy or breastfeeding. This makes treatment plans for the nearly 8 million people that are HIV positive in SA much more intricate.

Children are always the most vulnerable. We have made great strides in reducing mother-to-child transmission to below 2%. However, of the children who are born HIV-infected in the country, one out of two are born with the drug-resistant virus. That already limits treatment options and complicates the lifelong treatment of these children. In a country where an estimated half of the pregnancies are unplanned, transmission of the multi-strain virus from mother to baby is a very high risk since we cannot prepare the mother well for the pregnancy. However, when a mother’s HIV is well controlled during her pregnancy, the chance of transmitting HIV to her infant is very small.   

Starting treatment – and staying on it

When it comes to UNAID’s 90-90-90 target, South Africa is doing very well in meeting the first target of getting 90% of people with HIV knowing their status by 2020. However, when it comes to treatment – we are struggling to get people onto, and staying on treatment.

The social issues around the virus are rife. Denialism, a lack of understanding of the disease, the refusal of treatment and treatment fatigue are big issues that are still not getting the attention they deserve. Almost a third of the patients I treat have defaulted, which means they did not stay on treatment. They come in with other serious infections and are terribly sick.

It has been shown that about 40% of people who defaulted and started again have developed drug-resistant HIV. We are sitting with a problem where patients do not disclose they were previously on treatment because they think they might get into trouble or be denied treatment. When first-line treatment is administered, and it does not work, we assume they are not taking the medicine as prescribed, when they have actually developed drug resistance.

Socio-economic realities contribute to spreading drug resistant HIV

Violence, poverty and gender-based inequality make the spread of drug-resistant HIV a difficult battle to win. HIV prevalence among young women in SA is nearly four times greater than that of men their age.

The “blesser culture” has become a normalised concept, which not only highlights the low status women still have, but also the economic inequalities that force many women into these situations. An opportunity to get out of economic hardship can often outweigh the probability of getting HIV. Many young women are going into transactional sexual relationships with older men, in exchange for material goods. “Blessers” have multiple “blessees”, creating an environment for drug-resistant HIV to spread and thrive.

Until these issues are beaten, the HIV battle will not be won.

Light at the end of the tunnel

The gloom of this virus should not be overwhelming. Drug development and other advancements are happening all the time. In as early as 2019 South Africa will switch to a new drug, which is said to be more robust, much cheaper and viruses in the country do not seem to have resistance to it. If it passes all the safety tests, I think Dolutegravir will change treatment failure rates significantly.

There definitely is hope because drugs are improving all the time. People should not be afraid to be tested and start treatment as soon as possible. You can have a normal life expectancy if you start treatment early. In fact, in some cases infected people live longer than uninfected ones because they are well looked after, and more aware of their health.

Professor Theresa Rossouw is the Deputy Director of the University of Pretoria’s Centre for Ethics and Philosophy of Health Sciences, and an Associate Professor in UP’s Department of Immunology.