World AIDS Day 2008: One pill when the sun rises and one when it sets

As the sun rises in Homa Bay, in western Kenya's Nyanza Province, Pamela gets her two-year-old son Pascal dressed and ready for the day. At seven o'clock she sits with her husband Charles and father, mother and son all take their morning dose of antiretroviral drugs. All three are HIV positive and must take a tablet every morning and every evening for the rest of their lives.  As soon as he sees the brightly coloured tablet in his father's hand, Pascal reaches for it and puts it in his mouth. With a little water he swallows the pill easily.  The whole process takes a couple of minutes. Yet it has not always been this way.

It was only last year that a fixed dose combination (FDC) antiretroviral – one pill that combines the three different drugs needed to treat HIV/AIDS – for children became available. Pascal has only been taking them for a few months. Prior to that he had to take up to four or five different syrups containing the drugs he needs every morning and evening. Getting him to take them was no easy task, as Pamela explains: "It was a real struggle getting Pascal to take the syrups every day. He didn't like the taste and sometimes we had to hold him down and force him to take them."

It was also difficult for Pamela, who lives 40 minutes walk from the hospital where MSF runs its HIV clinic, to carry and store all the different bottles of syrups that Pascal needed. The bottles are quite heavy but rather than take public transport Pamela still preferred to carry them and walk home after her monthly appointments. In this part of Kenya, the stigma surrounding HIV is still very strong and many patients do not want to take public transport carrying the bottles which will identify that either themselves or their child is infected with the disease. Others cannot afford the 50 cents needed for the journey. For Pamela, with only one child, the walk carrying the bottles was manageable but for those patients with more than one child, living far from the hospital, it was tough.

Ensuring the right dosages were given was hard as the different syrups come with different size syringes or measuring cups. Half a syringe from one syrup might be equal to 50ml whereas with a different syrup it could be 25ml.  "We had many different bottles," explains Pamela, "and for each one we had to give Pascal a different amount. Sometimes I got confused and I'm not sure that I always gave him the right amounts." 

Giving children the wrong treatment dosage can have serious repercussions. But as there are still only a very limited number of paediatric fixed dose combinations available in tablet form, syrups are used by most governments as they offer more scope to combine different single drug formulations. Yet as Pamela's experience shows, the difficulty in taking these syrups can mean that children do not receive the right dosages and do not take their medication properly. MSF's experience treating patients with HIV shows that the simpler the treatment, the better the outcomes.

As MSF's medical coordinator, Helena HUERGA, says: "With the paediatric fixed dose combination our patients know they have to take one pill when the sun rises and one when it sets. In Homa Bay, where we're treating more than 1,000 children infected with HIV, we've seen the difference this drug has made. If we really want to reduce the number of child deaths caused by HIV/AIDS, existing fixed dose combination drugs need to be much more widely used and many more easy-to-use drug formulations need to be developed for children."

Of the 22 antiretroviral drugs currently available, nine are not approved for paediatric use and seventeen are not available in paediatric formulations. There is a clear and urgent need for more research and development of child-friendly antiretroviral drugs. Such research should focus not only on creating the best quality drugs possible, but also on producing drugs that are easy for children to take.

World AIDS Day 2008

> MSF Report "A preventable fate" 
> Brendan Bannon Photography Blog