By Oluatoyin Alleyne
Guyana could face a major public health crisis as drug resistant strains of the HIV virus and tuberculosis (TB) are on the rise, Head of the Genito-Urinary Medicine Clinic (GUM) Dr Jagernauth Ragnauth says.
In an exclusive interview with Stabroek News, Dr Ragnauth said he has already seen evidence of a resistant strain of HIV/AIDS where infected persons have failed the first line of treatment and have had to be placed on a second order of treatment. He said the second course of treatment is more expensive and can put a burden on the country’s resources. Further, Dr Ragnauth said that he knows of five cases of resistant strain TB and it is not clear whom the carriers may have infected, making it a major worry.
The doctor said stigma and discrimination coupled with patients not adhering to their treatment guidelines are the main reasons for the increase in these resistant strains. He said some persons also continue to engage in unprotected sex even though they are aware that they are HIV/AIDS infected. “If you don’t use [your treatment right]… it causes [resistance], resistance is the major headache, the major worry you have. What will happen to your population should there be resistant strain viruses out there being transmitted. We don’t know, we don’t have the resources in testing that, because I mean it is very expensive,” Dr Ragnauth told this newspaper. At his new office at the public health reference laboratory, Dr Ragnauth said too with these resources, such tests may eventually be done locally, though not in the near future.
Monumental task
Currently, the GUM Clinic has a record of 3,128 patients who are HIV/AIDS-infected with 981 from that number in active treatment and another 341 enrolled for care and support. That figure includes 172 children enrolled at the Clinic with 52 receiving treatment. There are about 1,000 or more persons that the Clinic cannot locate who have tested positive but never returned for treatment. Dr Ragnauth said the Clinic has since compiled a list of the names and phone numbers of the missing persons and it plans to check with the general registry office to ascertain whether any of the persons have died. “After that we would take the list to all the other treatment sites to see if the persons are accessing treatment,” he said.
Dr Ragnauth said his outreach staff members are encountering some difficulties in locating persons who may have slipped through the cracks because “We have realised that patients would have given us incomplete address, incorrect addresses, wrong names and wrong telephone numbers. And that is a problem, a major problem,” he said. He also said ideally he’d like patients to produce some form of identification when accessing the services of the clinic to ensure that they at least provide their legal names. “We tried it departmentally to see if it was going to work but in a way people were a bit hesitant to come forward… But that is one of the ways we would have to go,” he said.
Dr Ragnauth said it is more important to monitor the patients who are accessing treatment as another problem the Clinic has found is that the patients do not follow treatment guidelines. He said some patients use their medication like persons suffering with diabetes or hypertension would, meaning that they only take the medication when they feel unwell. “But you can’t do that with HIV treatment because what you do, you develop drug [resistance]…you are going to die faster,” Dr Ragnauth said, especially “if you are having unprotected sex, a lot of people are still have unprotected sex even though they are HIV infected… and they keep re-infecting themselves and others.”
He said most patients assure their caregivers that they are not having sex or that they are taking precautions and the truth is only revealed when their CD4 cell (a component of the immunity system) count and the viral load are monitored. The doctor said too although some patients may not be sexually active the said monitoring can also reveal whether they have been defaulting on their treatment. He said his major worry in this instance is that when patients are “defaulting on treatment, having unprotected sex [they] are exposing other people to resistant strain viruses, meaning… that those persons they infect from day one the treatment would not work.” Ragnauth believes that Guyana may soon face a “monumental” task in solving such issues.
Asked if he has already seen such a trend, Dr Ragnauth said there are at least two patients at the Clinic who have already failed first line treatment immediately after being placed on it and are on the second line of treatment. “When we asked them, they [admitted] having unprotected sex and those (who transmitted) to partners we started them on first line treatment and over a three month period we did not see any improvement and we did not want to waste time anymore… we have already started them on second line treatment…” He said that it is more costly to put patients on second line treatment as more tablets have to be used and the patient is at a greater risk of developing high cholesterol and other complaints. “So you have to deal with more issues and more problems when you are on second line treatment,” he explained.
Dr Ragnauth said too there are about 70 other patients who are also on second line treatment after using the first course for some time. Two children are numbered in this group. Another problem the Clinic has uncovered, he said, is that patients share their medication. He said that by engaging in this practice the patients are then creating more problems for themselves as they would then need a combination of three or more pills to fight the virus.
Meanwhile, Dr Ragnauth said he is hopeful that by year-end Guyana will be providing universal access to treatment, meaning that once a person is tested HIV-positive, the person is placed on treatment immediately rather than waiting for their CD4 count to reach a certain level as is currently the case.
Resistant TB
Dr Ragnauth said the resistant strain TB that can be transmitted via coughing is also cause for great concern as it is easily transmissible. “You can be walking down the street and people coughing and you don’t know what form of TB they have,” he said, explaining that its effects are more far-reaching as “you can be sitting on an aircraft and someone having resistance TB [coughs] and you can become infected.”
This explanation highlights the global panic last year when a suspected drug-resistant TB infected US lawyer travelled through Europe on an aircraft, possibly exposing fellow passengers on a series of commercial flights to an exceptionally dangerous form of the virus. “The mere thought of having those type of cases, it is a public health alarm because we need to make sure that we get those patients,” Dr Ragnauth said, adding that there are strains of multi-drug resistant TB in Guyana. “We had about eleven cases, from what I was told five of them died so at least we have about four or five of them still alive… and we don’t know they would have been infected since.”
Addressing
the problem
In an effort to address the problem of patients’ adherence to their treatment guidelines and to practising safe sex, Dr Ragnauth said they host regular talks at the Clinic. He also said that some patients are coping with many social issues and some do not have the funds to return for treatment on time. “But I always tell patients if they had to go to the US Embassy or had to go somewhere else they would have found that money to go,” he said.
The doctor said when a patient starts treatment he/she has to return to clinic two weeks after the starting date and then within another month in order to do laboratory tests to ensure that they are doing well on treatment. “As long as that initial two months pass you can have two months, five months sometimes six months treatment, depending on their CD4 count.”
Meanwhile, Ragnauth said stigma and discrimination remain major problems. He said perhaps that situation would change if a prominent person admitted publicly that he/she is HIV-infected and shows that he/she is able to continue living well while accessing treatment. “I am sure that there are prominent people in this country who have HIV… who can stand up on the bandwagon and start talking about HIV…. The Government is making an excellent contribution but people need a role model and it is not happening,” he said.
And, while a recent UNAIDS report said Guyana has about 13,000 persons living with HIV/AIDS, according to the National AIDS Programme Secretariat website at the end of September last year there were only 1,949 patients recorded as receiving anti-retroviral therapy (ARV). The website said that the estimated number of adults (aged 15-49) needing ARV treatment at the end of 2007 was 3,240. A number of treatment sites have also been opened countrywide: at the GUM Clinic, the Davis Memorial and St Joseph Mercy hospitals, in Bartica, West Demerara, New Amster-dam, at the Skeldon and Linden hospitals, in Rosignol and at the Dorothy Bailey, Campbellville, Enmore and Beterverwagting health clinics. Additional there is a roving medical team that serves the hinterland in regions one, seven, eight and nine.
