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Published at www.cmaj.ca on Jan. 7
Trezar Mnenula sits in a consultation room in Zomba Central Hospital in Malawi, eyeing her HIV-infected patient skeptically. "Why do you think you keep forgetting to take your ARVs [antiretrovirals]?" she asks.
The woman's explanation, that she "forgot" the seven leftover pills in her container, doesn't cut it.
Mnenula, a young clinical officer intern with red-and-black-framed glasses and long, tiny braids, says nothing, waiting for her patient to elaborate. Eventually, she sighs and says, "I'm going to send you for counselling again. Apparently the messages didn't sink in the first time."
It's become an altogether common occurrence in Malawi, and across Africa, driving fears that drug-resistant strains of HIV are emerging because patients don't adhere to their antiretroviral drug therapies, setting back a decade of gains in the battle against AIDS. Drug resistance occurs naturally over years of being on treatment, but can arise in just a few weeks if patients take their drugs intermittently. Antiretroviral therapy suppresses drug replication, but when there are low levels of drugs in the blood, the virus has the opportunity to replicate quickly and mutate into resistant forms.
"In many ways, resistance is a silent problem because we don't have the abilities to measure it," says Adrienne Chan, medical coordinator at Dignitas International, a Canadian organization facilitating AIDS treatment in Malawi. The cost of viral load tests, the best measure for resistance, puts them out of the reach of...