Adherence and ARV resistance

The Cape Argus in Cape Town, South Africa, published an article on 1 December 2006 under the headline "SA faces new Aids crisis as cheaper drugs lose their effect". The following quote from the article raises an alarm bell:

"Specialists point out that resistance is a given, even in settings like Khayelitsha where adherence rates are very high"

All resistance in microbes causing disease in humans develops when the microbes are exposed to an anti-microbial and some of the microbes survive the exposure. If the statement from the Argus above is true then it means one of two things is true. Either ARVs are not as effective as they are being made out to be (it is near common cause that properly implemented HAART causes near complete viral suppression) or patients are not as adherent as some are trying to make out.

The MSF project in Khayelitsha has long claimed that they have extraordinarily high adherence rates. Higher than anywhere in the world in fact. And higher than for any other condition in South Africa. Much, much higher than even TB which uses directly observation to measure and encourage people to take their medication. I find it highly implausible that this is the case. Frankly, I think that the HIV patients in Khayelitsha have as much difficulty with adherence as everyone else around the world does, and patients with other diseases in South Africa.

You see, it has become politically incorrect to suggest that there may be problems with adherence with ARVs in South Africa. Activists of all persuasions are correctly lobbying the government to gear up the ARV roll-out. If you suggest that patients will not take their ARVs as prescribed, this is perceived to weaken the argument for the roll out. Perhaps this is because the Ministry of Health initially used non-adherence as one of their concerns in delaying the roll our. Then MSF and others set out with various pilot projects to prove the minister wrong.

I don't know if the measure of adherence which they use is poor, or if subconsciously the desire to support a political end has skewed the results. Whatever the case, I am convinced that the growing levels of resistance to ARVs are caused by non-adherence. This doesn't mean that I think the ARV roll out should be slowed down. Rather, the problem of non-adherence should be faced head on and dealt with properly, rather than brushed under the carpet.