According to Pierre-Marie David of the University of Montreal’s Faculty of Pharmacy, stock-outs of antiretroviral (ARV) drugs in recent years in the Central African Republic have had a dramatic impact on the health of HIV-infected people. These shortages have also created mistrust among patients toward the political and medical actors responsible for the fight against HIV/AIDS. And their wariness is likely to reduce their chances of getting better. David lived in the Central African Republic from 2005 to 2008, where he worked as Access to Antiretroviral Treatment Coordinator for the Red Cross. He then conducted research on the social effects of ARVs in the context of that country. His findings were recently published in Global Public Health.

From hope to disappointment
The fight against HIV/AIDS is one of the eight “Millennium Development Goals” adopted in 2000 by the UN Member States. Under this objective, free access to ARVs has become widespread in various countries, including the Central African Republic. “In this way, around 14,000 people were able to receive treatment in 2011 in a country where prevalence of the disease was 5%, which is an epidemic generalized across the population,” says David.

However, ARV distribution has created disappointment equal to the high expectations it initially raised.

On the one hand, free access to ARVs offered the possibility of living better with HIV, which as a result, became a treatable infection like others. On the other hand, carriers of the virus were less stigmatized by the population, and the availability of medications resulted in a doubling in the number of pregnant women agreeing to be tested for HIV (20,000 in 2008 vs. 40,000 in 2009). But the management of funds - US $43 million - was centralized by an unprepared state apparatus. The distribution networks that existed before free access disappeared, leaving a monopoly system that had become corrupt.

So much so that, from 2008 to 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria sporadically froze payments to ensure greater traceability. The supply of ARVs was affected, resulting in stock-outs that sometimes lasted more than two months in areas of the country with more than 220,000 HIV-infected people.

Biological and social resistance

Noting the extent of the problem when he returned to Bangui in 2010, David reframed his work to include the individual and social effects of treatment discontinuation. “Paradoxically, these shortages, in both real and symbolic terms, were a death sentence for those whom the drugs were supposed to save,” he says.

On the one hand, many patients suffered virologic failure (or treatment failure) due to the strategies they used to compensate for a lack of ARVs. “For example, some people took their medications only every other day so they would have some left over in case of a shortage, while others relied on local healers in the absence of treatment,” recalls David. Such strategies likely increased the risk of drug resistance.

On the other hand, treatment interruptions were also interpreted by patients as a betrayal of those responsible for international programs. “In addition to biological resistance, I also noted social resistance, indeed a kind of cynicism,” explains David. “And if, in ten years, we decide to give them second or third generation drugs to treat drug resistance, we will first have to ask how the development of new programs will be interpreted.”

In other words, patients may reject these programs, and we will be deceived into believing that these men and women are refusing treatment for cultural reasons.

“However, there will be historical reasons for this social resistance, and in this sense, current stock-outs will be an explanatory factor for adherence or non-adherence to future treatment programs,” he concludes.

About the situation in the Central African Republic

Since 2013, the Central African Republic has engaged in its third civil war, caused primarily by problems of governance that have degenerated into communal conflict between Christians and Muslims in a region greatly destabilized by fighting in Darfur and the Democratic Republic of Congo (DRC) and the spread of armed militias over a large part of the area.

According to the UN, the country is in the midst of a humanitarian crisis: half of the 4.6 million inhabitants of the Central African Republic are in a “state of humanitarian assistance,” with 400,000 internally displaced and 68,000 refugees in neighbouring countries, mainly the DRC. In addition, approximately 1.1 million people are affected by food insecurity.

The situation deeply concerns David, not only because of the additional difficulties it raises for ARV distribution, but also because of the situation of survival it has created for the entire population. “Access to ARV treatment becomes problematic in the context of daily survival in a country that already generates little interest,” he laments, recalling that less than 40% of basic humanitarian needs are currently filled. A call for international commitment.

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Notes

Pierre-Marie David published “Towards the embodiment of biosocial resistance? How to account for the unexpected effects of antiretroviral scale-up in the Central African Republic” Vol. 9, Iss. 1-2, 2014 of Global Public Health. The following funding acknowledgement appeared in the article: “This research has been supported by a PhD fellowship from the Méos, a research group on medication as social object at the University of Montreal and a Young Researcher Fellowship from Sidaction, Paris, France.” The University of Montreal is officially known as Université de Montréal.

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William Raillant-Clark
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University of Montreal