Catherine Murombedzi
Health Correspondent

Antimicrobial Resistance (AMR) poses a significant threat to people living with HIV/AIDS, who rely on life-long antiretroviral therapy (ART). Missed doses, substance abuse, the faith healing factor, and poor adherence to treatment can lead to drug resistance and treatment failure. As a result, AMR can render HIV treatment ineffective, leading to premature deaths.
In Zimbabwe, the rise of AMR is particularly concerning, with an increasing number of people living with HIV/AIDS experiencing treatment failure.
The country’s healthcare system is already strained, and the growing threat of AMR only adds to the challenge. AMR can be prevented if awareness is amplified.
According to statistics from the National Aids Council (NAC), as of June 30, 2022, there were 499 patients on third line treatment. As of June 2023, there were 533 patients that translated to an increase of 34. In 2018, only 36 patients were on third line treatment.
In June 2023, the second line treatment had 48 937, a decrease from 49 946.
A total of 1009 could have died or did not come back for resupply or were lost to follow up.
The second and third line regimens are purchased using domestic funding from the Aids Levy.
The Aids Levy is pooled from 3% tax, of the taxable amount of a formally employed worker. Will Zimbabwe be able to cater to the growing numbers of those getting drug resistant HIV?

AMR threatens the gains achieved in the local response.
Experts emphasize the need for treatment literacy, adherence counseling, and addressing substance abuse to combat AMR.
By taking action to address these factors, we can help protect the progress made in HIV treatment and ensure that people living with HIV/AIDS continue to receive effective care.
Globally, AMR is growing and is an urgent crisis. It is a leading cause of untimely deaths globally. More than 2 people die of AMR every single minute. AMR threatens to unwind centuries of progress in human health, animal health, and the environment.
Zimbabwe has no data on AMR deaths.
AMR is a problem driven by misuse and overuse of antimicrobial medicines, including antibiotics and antivirals, and results in critical medicines losing effectiveness to treat infections.
AMR is a gathering storm that threatens progress in medicine. We take for granted that infections that once spelled death are routinely cured with antibiotics and antivirals.
In the age of ever more advanced and personalised medicine, we have grown complacent about these marvels that allowed us to bring infections under control. Adherence is required for the treatment to be effective in suppressing the Human Immunodeficiency Virus. HIV attacks and weakens the immune system.
Anti HIV treatment ranges from the first line. If treatment on that regimen fails, a patient is moved to the second line. If the second line fails, one is moved to the third line. Take note that there is no fourth line. If a patient fails third line treatment, one books an early berth into the graveyard.
Moud Chinembiri, a young mother of two working with young people living with HIV speaks of the growing risk of AMR.
“As a young mother of two who underwent the same, I understand why people stop taking medication due to internalized stigma. The voice that taking medication means I am worthless is crippling. So this mentally limits one. As young people living with HIV they face shame. They ask the question? ‘Why me? Why am I different, I am a black sheep.’
This is rife in families where other children are HIV negative. So, the young HIV positive person just stops taking medication.
“At times, the HIV status was never clearly explained. At first, one was told that it’s treatment for pneumonia or a recurrent unexplained disease. So the moment they get to understand, they get angry and stop taking treatment.
“One feels that the community knows that I am HIV positive. As they grow up and start to date, disclosure is difficult. One can even get into marriage without disclosure. Taking medication becomes a mouse and cat issue. At times, one fails to take treatment or even fails to collect. With missed doses comes treatment failure. We have witnessed this as young people living with HIV. We have lost some young people as the virus becomes resistant after several missed doses.
“Then environmental aspects and changes in weather even affect us. Life is getting hard, so as a person living with HIV, the blow is harder. So one gives up, the self stigma becomes a barrier to taking treatment,” said Chinembiri, who sits on the Pan African Positive Women’s board representing young people.
Dr Enerst Chikwati, Country Programme Manager for Aids Healthcare Foundation (AHF) said the rising treatment failure numbers could be attributed to many reasons: From missed doses (non-adherence), to lack of, or poor or non-use of effective diagnostic tools to a shortage of health personnel.
“There has been an increase in the number of patients needing third line treatment,” said Dr Chikwati.
“However, this could be due to increased availability of viral load testing, which has made us see more patients with a high viral load. Also, the ongoing training of health care workers has increased coverage of testing services and discovery of drug resistance and, therefore, increased demand.”
Dr Chikwati acknowledges that the main cause of treatment failure is drug resistance as a consequence of poor adherence over the years.
“But other factors such as under-dosing in children, drug-to-drug interactions, and other structural factors come into play,” he added.
He pointed out that when children’s doses are out of stock, centers issue adult doses, informing parents and guardians to break the tablets before administration. This is risky as it could result in either overdosing or under-dosing and, eventually, treatment failure.
Dr Chikwati emphasized the need for treatment literacy among patients.
“Educate patients well so that they understand the importance of adhering to the lifelong treatment. Empower health-care workers so that they are better in managing patients at all levels and detect early treatment failure and intervene to strengthen enhanced adherence counseling to patients,” emphasised Dr. Chikwati.
AHF runs five centers of excellence as partners to Zimbabwe’s Ministry of Health and Child Care (MoHCC), offering comprehensive prevention, diagnosis, treatment, care, and support in the HIV response.
An expert in the HIV and Aids sector at Newlands Clinic, Harare, Dr Cleopas Chimbetete noted poor adherence as the reason for treatment failure.
“The main risk to treatment failure is due to missed doses. The majority of tests we run show resistance to the drugs used. Patients collect medications religiously, but for reasons best known to them, they stop taking drugs as prescribed. Over 90% of treatment failure is due to missed doses. Treatment must be taken at the agreed time, every day. Patients must not take alternative medications and supplements not approved by the doctors. Sadly, many unorthodox medications are being sold as magic treatments. These unverified medicines interact with prescription drugs, rendering them ineffective,” said Dr Chimbetete.
“The other way that one can have treatment failure, yet they have never missed a dose, is when they get re-infected, cross-infection can cause treatment failure. We urge PLHIV to always use protection. If they get a drug-resistant strain from a partner during sexual intercourse, it means the treatment in force will not work. So always condomize,” said Dr Chimbetete.
He emphasised adherence as well as avoiding substance abuse.
“We need to address the issue of poor adherence. About 90 percent of people on second and third line treatment missed their doses of the first line regimen. Young people struggle to take drugs as prescribed. Substance and drug misuse is also a contributor to lack of adherence. With mutoriro (chrystal meth) misuse, for instance, we notice a rise in young people failing to adhere to treatment,” he said.
Shepherd Sande, a drug addict on his recovery journey, agreed that he missed doses.
“I did not deliberately miss taking my treatment, I was drunk for days. I blame my friend who had me addicted to mutoriro in high school. I am trying to adhere to treatment now because I am on third line.
“If science gave us ARVs, then they should give us an injection once a year for treatment. In fact, I am now asking for a vaccine to prevent infections. If it delays, we, the youth, are surely going to die,” Sande commented.
Research and development are at work.
In some countries abroad and in Southern Africa, South Africa, an injectable treatment for HIV called Cabenuva (cabotegravir and rilpivirine) is now available. Cabenuva is a long-acting injectable, which is administered every two months. This treatment is used in combination with other ART medications to treat HIV-1 infection in adults, reducing pill burden.
It is effective in achieving and maintaining viral suppression in those at risk of drug resistance. A doctor at Sally Mugabe Referral Hospital, Harare, speaking on condition of anonymity, said the majority of admissions at the hospital are due to drug resistance. Patients on life treatments would have stopped taking medication.
“I have worked in a public hospital for 20 years. Religious beliefs are now major risks. It used to be the white garment sector, but now, Pentecostal churches are taking the lead. The majority of treatment failure admissions wear arm bands inscribed with their leaders’ names. The mantra: ‘By your faith you are healed’ books an early cemetery for its followers who would have drug resistant strains,” said the doctor.
Several countries in Asia and Africa have observed a worrying trend of increasing drug resistance, while progress towards AMR containment efforts remain scattered and fragmented.
AMR is not only a major problem but a problem with a solution. There is a lot we can do to combat AMR.
“Lack of recognition of the problem at the highest level of governance, limited technical capacity and financial resources, weak regulatory apparatus, half-hearted efforts towards instilling behaviour changes at all levels of healthcare have prevented the effective application of several interventions to minimize the impact of AMR. Countries need to invest in strengthening healthcare systems and prioritising prevention interventions, like infection control in hospitals and communities, and vaccinations,” said Dr Kamina Walia in a virtual conference. He is the Convener and Co-Chairperson of Scientific Committee of Global AMR Media Alliance (GAMA).

AMR is a global health threat that requires a collaborative and multi-faceted approach to address. It needs all hands on deck.
Governments must develop and implement policies, regulations, and give enough funding to combat AMR.

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