HIV Specialist - June 2021 - 29

A national HIV treatment program was started in 2004 and it
fueled progressive declines in incidence.3 In 2013, all pregnant PWH
became eligible for ART. As of 2016, all PWH were offered ART regardless
of CD4 and clinical stage. Expanded ART access had a major
effect, as vertical transmission rates were halved from 2012 to 2015.4
We followed some 500 HIV-exposed babies once a week, and thankfully
94 percent of them turned out to be HIV negative.
Some 200 HIV Teen Club members met each month at our clinic,
as they danced, performed skits, and otherwise supported each other
and their improved adherence. Meanwhile, our nutritionist cooked
healthy food with families while teaching gardening methods. With
these and other programs, we were able to prevent and treat most
cases of malnutrition without the need for a hospital stay.
Missing Labs and Medication
Despite these successes, our clinic dealt with many of its own challenges.
We often ran out of CD4 cartridges, bacterial cultures, lumbar
puncture needles, and HIV rapid tests. Meanwhile, VL results could
take a few months to come back from the Ministry of Health (MOH).
We lacked resistance testing but made ART switches based on a lack
of VL response that occurred despite intense adherence counseling
and presumed improved adherence to HIV therapy.
As a public clinic, we were also dependent on the MOH for our ART
supply. There were frequent ART shortages throughout the nation,
which explained why the village clinic was giving nevirapine to our
malnourished patient. It was the only HIV anchor medication available
at theirs and many other centers. Therefore,
it was given despite the fact that up to 60
percent of children with HIV in sub-Saharan
Africa have pretreatment resistance to
non-nucleoside reverse transcriptase inhibitors
(NNRTI).5 HIV treatment guidelines in
Tanzania are routed in evidence-based World
Health Organization (WHO) guidelines for
resource-limited nations.6 At that time, these
guidelines called for patients like him to be on
lopinavir/ritonavir and lamivudine/abacavir
for first line ART.7
However, lopinavir/ritonavir syrup
needed to be refrigerated and most of our
patients lacked electricity. Further, this syrup
is foul-tasting and therefore rejected by many
children. Although we could offer our patient
this ART combination at our center, we later
ran out of lopinavir/ritonavir syrup as well as
oral tablets. For this reason, suppressed patients
had to be switched to older therapeutic
options such as efavirenz or nevirapine
because we had no other anchor medications
available based on patients' weight.
Frequent switches were confusing to
patients and staff, and they were sometimes
responsible for viral failure or severe drug reactions
such as Stevens-Johnson Syndrome.
At one point, we had such a short supply of
ART that we could only dispense two weeks
of meds at a time. This was very trying for our
patients who travelled far to reach us. This
also meant that a few clinicians saw over 130
patients daily, stirring Tanzanian Clinicians
to leave for other practices.
The 2019 rollout of dolutegravir in
Mwanza, Tanzania
Tanzania was a breath of fresh air. We
switched over hundreds of patients from less
effective regimens with higher pill burdens
and poor tolerability due to drug side-effects.
Yet we did not have a reliable supply from the
MOH, so it joined our constantly changing
list of ART which was out of stock. Although
Tanzania approved the use of pre-exposure
prophylaxis (PrEP) in 2019, we did not have
enough Emtricitabine/Tenofovir DF to offer
it (nor were we approved by the MOH to do
so). We ran out of various antibiotics at times,
but thankfully, our stock of TMP/SMX was
maintained. However, they often lacked it in
the rural areas where we trained HIV providers
and there were many lives unnecessarily
lost to PJP as a result.
WWW.AAHIVM.ORG HIVSPECIALIST JUNE 2021 29
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HIV Specialist - June 2021

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