Tenofovir (TDF), used by roughly two per cent of Rwandan adults fighting HIV, will replace the out-dated drug recommendation. It will be one of three antiretroviral drugs combined to make the premier option for first line therapy for adults.
“The national guideline is the main tool used to determine which treatment a patient will be starting,” said Dr. Sabin Nsanzimana, Care and Treatment Department Coordinator at TRAC Plus. A patient’s treatment is then reviewed and changed accordingly. “The first line is the main line and then it can be changed for particular patients.”
All new HIV patients will be given a combination of TDF, lamivudine (3TC) and nevirapine (NVP) or efavirenz (EFV), unless there are other health complications, Nsanzimana told RNA.
Since 2003, Rwanda has distributed different combinations of ART treatment to reduce the number of people who die from AIDS-related complications, the new guidelines state. Typically, a combination consists of three categories, or families, of ART drugs, Nsanzimana explained. Within each category, there are drug options to choose from. “You can’t change AZT for 3TC. Drugs have to be in the same family.”
The 2007 guidelines (which are in use until the 2009 guidelines are applied later this month) recommend the use of zidovudine (AZT) or stavudine (D4T) for adults, in conjunction with two other categories of drugs. In the past, two types of D4T were available. The 40mg dosage was stopped in 2008 due to side effects. “The 30mg is used by patients who were originally on the drug and have not had side effects,” said Nsanzimana, but added that the drug is slowly being weaned out.
AZT and D4T based regimens are the most widely used in Rwanda. According to statistics obtained from TRAC Plus, as of March 2009, more than 50 per cent of adult patients were on a D4T based regimen and 44 per cent were on an AZT regimen. Just over two per cent were on TDF and about one per cent on abacavir (ABC). The reporting rate for the study was 88.89 per cent.
TRAC Plus reviewed and revised the guidelines based on evidence from studies done in Rwanda, Africa and internationally. Treatment failure, numerous side effects, drug intolerance, and increased difficulty in finding alternative treatments – all are more common of the two most widely used drugs in Rwanda, than the newly recommended TDF based therapy, the 2009 guidelines state.
Further, patients are more likely to continue taking their treatment if on TDF because both AZT and D4T regimes are dosed twice daily, where TDF is a once-a-day dose, the guidelines highlight.
But TDF also has potential side effects, such as kidney disturbance. “Not all new patients will receive TDF due to conflicting health concerns,” said Nsanzimana. Also, patients currently on AZT or D4T will only switch if they are experiencing problems. The majority of patients do not have adverse effects, said Nsanzimana. “So we’re not going to take a beneficial drug away from someone because others have reactions.”
Before TDF is prescribed to new patients enough stock needs to be available at CAMERWA, Rwanda’s drug procurer and distributer. Currently 49,095 packs of 30 tablets containing TDF and 3TC combined have arrived, according to the commercial director of CAMERWA, Jean Claude Tayari. TRAC Plus is finishing training health providers on how to implement the new guidelines and after a meeting with district hospitals this August, new patients will fight HIV with TDF.
But changing the first choice therapy is not the only news affecting recently diagnosed HIV patients. All new patients will take another pill – but not an ARV drug. “Prophylaxis treatment” curbs opportunistic infections. Nsanzimana explained that the treatment fights diseases that take the opportunity of a weak immune system to infect the body. Currently, the drug is only given to people with HIV who have low immunities. But that it to change based on evidence that is prevents death among all people who take it, even those with strong immunities.
In Rwanda, there are first line and second line treatments available for patients. Within those lines there are several options of combinations, but each line has a recommended first choice.
For the first line regimen, the pre-existing recommendation of AZT or D4T based treatment for all Rwandans will be changed to TDF based for adults and ABC based for children.
The second line regimen, which was based on TDF or ABC, will now be switched to AZT or D4T.
The number of HIV-positives adults on ART continues to increase in Rwanda. According to fact sheets from TRAC Plus, 70,234 Rwandans were on antiretroviral drugs in June 2009 compared to 51,652 adults in June 2008.