Why hunger is driving thousands to abandon the drugs that keep them alive

Starving HIV and TB patients are shunning their medication as the side effects on an empty stomach are too severe

Crippling hunger has driven Vitola Genti to the brink. The 67-year-old, a refugee in Malawi, has HIV and is dependent on antiretroviral drugs to keep the virus dormant in her body.

But in the aftermath of Cyclone Freddy, which hit the country in March and has caused widespread hunger, Vitola now forgoes her medication. The side effects on an empty stomach are agonising and unbearable.

“I stopped taking my antivirals regularly from last month as I could not stand the side effects,” she says from a refugee camp in the south of Malawi. 

In shunning the drugs, Vitola knows she is at risk of dying from her HIV infection, which could develop into Aids if not suppressed. But until she’s able to buy food and take her medication free of pain, it’s a risk she’s willing to take.

“It’s something you can’t imagine at all,” she adds. “I feel dizzy, weak and sometimes [suffer from] abdominal pains.”

Vitola isn’t alone. After the Malawian government stopped providing food to the victims of Cyclone Freddy last month, many have stopped taking antivirals because of the side effects that arise from consuming the medication on an empty stomach.

In total, some 838,000 people are dependent on antiretroviral therapy in Malawi. Across Africa, 16.3 million patients have access to the treatment.

The Global Fund, which invests billions each year to fight Aids, TB and malaria, told The Telegraph that it had noticed a rise in the phenomenon across parts of Africa as food insecurity has surged, driven partly by the Russian invasion of Ukraine.

“From our clinical and public health experience, we know that a patient who had nothing to eat during the day would be less motivated to take any medicines,” says Dr Mohammed Yassin, a senior disease advisor at the organisation. 

It’s a similar story with tuberculosis, which also requires an intensive medication programme to treat. Some patients are prescribed daily and weekly drugs for up to six months, yet several papers have shown that food insecurity can affect treatment adherence.

In a 2019 review of 44 studies on TB treatment adherence, five said patients stopped their medication when they could not access food. Among the factors at play, side effects were commonly reported by patients as a reason for TB therapy discontinuation.

As with HIV, the decision to forgo TB drugs can prove fatal. Estimates suggest half of patients who go untreated may die within 5 years; this risk would be higher for those with drug-resistant TB or co-morbidities.

The side effects associated with HIV and TB medication can take many forms, ranging from fatigue and nausea to body pain and joint aches. In many instances, taking these drugs on an empty stomach can exacerbate the side effects.

Some drugs, such as antiretrovirals, are made up of large compounds which irritate the stomach lining and are poorly absorbed. Taking them with food coats the chemical compounds with a layer of fat which helps ease their passage across the gut cell membranes, reducing irritation.

‘It’s a complicated problem’

Other drugs, like TB medication, are meant to be consumed on an empty stomach to ensure full absorption, but this too can trigger a strong reaction from the body. 

Penny Ward, a visiting professor in pharmaceutical medicine at King’s College London, says the shunning of medication among hungry patients fearful of side effects is a “complicated problem” – one that has arisen from rising food insecurity rates across the world.

The World Food Programme reports that a record 349 million people across 79 countries face acute food insecurity. This all-time high represents an increase of 200 million compared to before the Covid pandemic.

The war in Ukraine has proved especially catastrophic. As well as reducing the exports of grains and oilseeds, it has also affected the consumption of other, more nutritious foods.

In East Africa, the price of a local basket of food increased by more than 55 per cent in the 12 months to November 2022, according to the WFP. The price of imported wheat alone has increased by more than 58 percent since Russia’s invasion.

Experts have also warned of rising food insecurity across the Middle East, a region with high levels of dependence on food imports from Russia and Ukraine.

The war has also affected the provision of humanitarian assistance worldwide: the WFP’s monthly operating costs today are $73.6 million more than their 2019 average, representing a 44 percent increase, primarily resulting from the rising price of fuel and food aid.

Against this backdrop, more and more people from low and middle-income countries are going hungry, unable to access food due to exorbitant market prices or overlooked for aid by humanitarian groups and governments.

As one of the many knock-on effects of hunger and malnutrition, the eschewing of HIV medication carries particularly catastrophic consequences – not just for a patient, but the community in which they live.

Karen Msiska, a spokesperson for the National Aids Commission in Malawi, warned that such behaviour may fuel HIV drug resistance, increase a patient’s viral load and, eventually, allow the infection to easily spread through unprotected sex.

“Skipping antivirals on and off may result in the virus developing drug resistance,” he said. “A patient’s viral load will be compromised and we may lose that person. The chances are also very high for that person to transmit the virus to someone living negatively, which threatens the country’s agenda to end HIV as a public health threat by 2030.”

Msiska described the situation as worrisome, especially given that Malawi already has a high HIV prevalence rate of 17 per cent in seven districts that were heavily hit by Cyclone Freddy. Nationally, the HIV prevalence rate stands at six per cent.

His sentiments are echoed by Maziko Matemba, the country’s community and public health ambassador, who urged the government to take immediate action in providing food to the hundreds of thousands of people displaced by Cyclone Freddy.

“The government needs to revisit its social protection and rescue the people from hunger to save their lives from untimely death as a result of defaulting from treatment.”

Source: The Telegraph

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By Samuel Lovett and Henry Mhango Nsanje

Published: July 4, 2023, 4:08 p.m.

Last updated: July 6, 2023, 3:14 p.m.

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