Are antibiotics as preventatives needed in "test and treat" era?

KAMPALA, UGANDA — Septrin is a drug used in antiretroviral therapy, but is not an antiretroviral drug (ARV). ARVs disrupt the reproduction of the HIV virus, whereas Septrin is a combination antibiotic that fights against infections that those living with HIV are vulnerable to until the levels of the virus in their bodies is made low by the ARVs.

Dr. Stephen Watiti, a medical doctor at Mildmay Health Centre, said that for more than a decade, Septrin was  given to those living with HIV whose CD4 count was above 350. Because drugs were relatively scarce, patients were not prescribed ARVs until the patient’s immune system was failing.  The Septrin kept opportunistic infections at bay even though the patient’s immune system was compromised by HIV.

A patient’s CD4 count indicates how well their immune system is performing by measuring the number of T cells (specific white blood cells) that are still functioning in the body and protecting against infection.

Today, patients receive ARV treatment immediately after a positive diagnosis, no matter their CD4 count at the time of diagnosis.

But in late 2016, the Ugandan government mandated “test and treat” guidelines where a patient was put on ARVs immediately after testing positive for the virus that causes AIDS.

When drugs were scarce in the days before test and treat was national policy, Septrin (cotrimoxazole) was given to those living with the HIV virus to combat opportunistic infections such as Pneumocystis jiroveci pneumonia, diarrheal and malaria.

There have been local shortages of several antiretroviral drugs and complementary drugs throughout Uganda for the past five months.

A drug shortage occurs when all medications stocks have been exhausted, putting HIV patients at risk  from infection and potentially causing them to build an immunity to the specific drugs that have been suppressing the virus.

“People living with HIV who are on ARVs with undetectable viral load can do without Septrin for a few days without any risk,” said Dr. Watiti.

Doctors at a local community hospital in Bwindi test blood samples for HIV and Tuberculosis. (Courtesy photo by Sally Forthwit | Creative Commons)

Unfortunately for Salima Zubeda, a few days turned into three months without medication.

Zubeda tested positive for the HIV virus in December 2004.

Like many others affected by the drug shortages, Salima was faced with an ultimatum—buying her medication from a private pharmacy or watching her health deteriorate.

“I always buy for the safety of my life,” Salima said when asked about how she acquires her medication when there are shortages of Septrin for an extensive period of time.

“For example, from my clinic, the Septrin is out of stock. But because we need to survive longer, we have to buy [Septrin],” she said.

Zubeda recalls going through a series of emotions during the Septrin shortages.

“I lost hope. [I thought] the chances of getting treatment was no more.” Zubeda says.

During these shortages, many individuals living with HIV are at risk of experiencing health-related issues and they face significant challenges in trying to obtain medication.

Salima did not succumb to opportunistic infections, but she experienced mental and physical stress causing her to lose weight rapidly and lose her sense of understanding.

Zubeda has hopes that the Ministry of Health and medical professionals in Uganda, can come together to find solutions to the Septrin shortages in Uganda.

“They should emphasize bottom -up planning so that the stock of the medication [Septrin] is adequate based and matching the affected,” she said.

The Ministry of Health said they are currently conducting a policy review on the current guidelines for providing Septrin to those individuals living with HIV and indicated that they may prioritize expectant women, children and patients new to antiretroviral therapy for receipt of the antibiotic. The MoH said this might ensures that currently scarce resources will be dispersed properly.

The Ministry of Health says it will fully restock Septrin by July 2018, according to a press statement in May from the MoH.