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Siyayinqoba Beat It! Episode 23 -

ARV resistance and new regimens

This episode was about understanding drug classes and how ARVs work. Dr Majoro, an HIV clinician and traditional healer joins our support group and helps us to better understand our drug regimens and the importance of adherence. We head out to Khayelitsha where Médecins Sans Frontières help Monwabisi Bikwana make a special application for an antiretroviral which is not yet registered in South Africa.

Shalom Ncala: Sanibonani, siyani amukhela kuSiyayinqoba Beat It! support group. Igama lami ngingu Shalom Ncala. Iqenjeni leSiyayinqoba Beat It! sonke siphila kahle ne HIV. Nanhlanje sino Dokotela Trevor Majoro usebenza eHIV clinic no phinde futhi abeyinyanga yesintu. Siyaku amukhela doctor Majoro. I viki ngalinye siyahlangana ukuzo xoxisana ngezindaba ezithinta izimphilo zethu. Ukusukhela kumi phumela imibi yamaARVs kanye nokhu vivinyela iHIV ngokuzithandela. USiyayinqoba ngu hlelo lwakho lokhu phila kancono nge HIV.Uma uphila negciwane le HIV, noma unomlingani, ilunga lomdeni noma umngani ophila negciwane leHIV iSiyayinqoba he yakho. Kusiyayinqoba support group sonke siphila negciwane leHIV.Sanibonani nonke. Namhlanje sikhuluma ngama klasi wamaARVs ukwaliwa wamaARVs womzimba waloyo owaphuzayo phecelezi iresistance kanye nama regimens amasha. Masebhekheni ukuthi ababukheli bethu bathini.{IsiZulu} [Hello and welcome to the Siyayinqoba Beat It! support group. My name is Shalom Ncala. In Beat It! support group, we are all living positively with HIV. Hello everybody and welcome. How are you guys? Welcome to today’s show. Today we are joined by Dr Trevor Majoro an HIV clinician who’s also traditional healer. Welcome Dr Majoro. How are you? Each week, we get together to talk about issues that affect our lives, from side effects of ARVs to voluntary HIV testing. Siyayinqoba is your guide to better living with HIV/AIDS. If you are living with HIV or you have a partner, a family member or a friend living with HIV, Siyayinqoba is for you! Today we are talking about drug classes, resistance and new regimens. Let’s see what our viewers have to say.]

Question: What do I do if I need a new drug regimen?

Shalom Ncala: Le programme esiyenza namhlanje understanding ama-drug classes ukuthi amaARVs asebenza ngeyiphi dlela. Into isizoyiyenza khonamanje bengicela ukuthi sisunkumeni sibekhe amadrugs wethu phezulu kwetafula lapho a belonger khona according to iclass yabo. I think we have stories ukuthi sifike kanjani khule regimine esikhuyo khona manje.{IsiZulu} [Today’s programme is about understanding drug classes and how ARVs work I’m going to ask everyone to put their drugs on the table, according to the class they belong to. I think we all have stories of how we got to their specific regimens we are on now. If any one is willing to share the story, how did they actually get to these regimens they are on now.]

Fanie de Villiers: [I was stupid. When I started my medication in the mid-90s, I was much younger. And I couldn’t deal with the fact of being HIV positive, so I was running around and wanted nothing to do with it, I definitely didn’t want to listen to the doctors. And, another part of it was, because I was trying to hide it. None of my friends knew. I didn’t feel well at all. My friends picked up on this and I was too scared to tell them. So I decided to stop taking the tablets without the doctor’s consent, ‘bogger die pille’] {Afrikaans}

Shalom Ncala: What I pick up from your story Fanie, you became resistance simply because you just dropped out, you told yourself never again, you will never take anti-retrovirals until you became sick again. You were started on another type or regimen, after you had stopped and do you know perhaps why that is?

Fanie de Villiers: I became resistant to the first regimen, and once you’ve become resistant to the first line of drugs, you can’t use them again, which is actually, in a sense, really bad. [You hear people who have been on the first line regimen for ten years. I regret that but I can only hope for the best.] {Afrikaans}

Nokhwezi Hoboyi: Kucase yami, mangi qala ukuqala itreatment, bengingaka understandi ukuthi yini iHIV. Well, wangi nika I treatment in 2002. Ngo may mangibona ukuthi ngibuyela emzimbeni ngayiyeka I treatment. Ngaqala ngagula towards 2003, u2004 ngangigula unyaka wonke. Ngathi mangise hospice mangichazela udoctor, ngake ngathatha amapilisi a sososo, wangibuza ukuthi aphi? Angizange ngiwalahle ngiwabekhile edlini, wathi edlini mabeze naloma pilisi. Wangi phathela uma,ehospice, ngaqala with the same iddI, d4T ne stoctrine. ICD4 count yami mangi buyela in 2004 beyithi 3,so iCD4 count yami inga khuphiki, that is when udoctor wami wathi no we need to do igenotype test to check ukuthi ngi resistance kwini na? Amaresults abuya athi ngi resistance to iEfavirenz (Stoctrine) and ngabe ngine peripheral neuropathy ebuhlungu udoctor wami had to atshintshe id4T le wangi nika iTenofovir, njengoba manje ngithatha i3TC, Tenofovir and Kaletra. {IsiZulu} [In my case, when I started taking treatment, I didn’t understand what HIV was. I started taking my treatment in 2002. In May the following year when I felt better, I stopped the treatment. I started feeling sick towards the end of 2003. I was sick throughout 2004. I moved into a hospice, and I told the doctor that I used to take treatment. He asked me ‘where is the treatment now?’ I told him I still have it. My mother brought the treatment to the hospice, and I started with the same treatment again: ddI, d4T and Stocrin. In 2004, my CD4 count was 3, and it was not improving. That is when my doctor suggested we do a genotype test to check which drug I was resistant to. The results showed that I was resistant to Efavirenz (Stocrin). I also had peripheral neuropathy, so my doctor had to take me of d4T and replace it with Tenofovir. So now I’m taking 3TC, Tenofovir and Kaletra.]

Shalom Ncala: Ukuqala kwami ukufinder out ukuthi ngi ne HIV, ama ARVs were not available. [When I first discovered that I was HIV positive, ARVs weren’t available.] And it was round about 2001, and I joined a clinical trial where I was offered Efavirenz. But due to other psychological effects benginazo in trems of bengi ne dementia and futhi bengingaka accepty istatus sami kahle. Kwabe ne reaction estrong kuStroctrine, eyalidela ukuthi nginga thathi iStocttrine anymore. That is way ngagcina ngikulama regimens.{IsiZulu} [But due to other psychological effects it had, I had dementia and I had not accepted my HIV status. I had a strong reaction to Stocrine which led to me not being able to use Stocrine again. That is why I ended up on this regimen that I’m on now.]

Dr Trevor Majoro: I-Stoctrine siyesingathandi ukunikeza abantu abane history ye mental illness, siyesingathandi ukunikeza abantu abathatha ama psychiatric medication. Because iStoctrine sinalento abayibiza as neuro-psychiatric side effects. For example siya interfere nobuthongo bakho and singakunikeza ama-nigthmares. So hence we advice abantu abaphuza iStoctrine basiphuze mabayolala because sifuna ukuthi a benefite from the drug while lele. Ungamane uphuphe khabi than wenze izinto izimbi uvula mehlo emini. So if people experience ama-side effects anjalo we-Stoctrine. {IsiZulu} [Stoctrine is not ideal for people with history of mental illness or people who are on psychiatric medication. Stocrine has what we call neuro-psychiatric side effects. It can interfere with your sleep and give you nightmares. This is why we advise people to take Stocrine when going to bed because we want the patients to benefit from the drug while sleeping. You’d rather have nightmares than react negatively while awake. If people experience such side-effects from Stocrine] we encourage them to take it and it’s important to tell them before they take them then they may have such side- effects but not everybody does have them.

Shalom Ncala: [We will talk more about ARV drug classes and new regimens.] {Sesotho} Sizobuya kungekhudala no doctor Trevor Majoro ukuze asisize ukuchazulule lenkinga {IsiZulu} [We’ll be back with Dr Majoro to explain more after the break.]

Shalom Ncala: [Welcome back to the Siyayinqoba Beat It! support group,] {Sesotho} Uhlelo lawonke umntu ongenwe futhi otithekayo kwi HIV. Namhlanje sikhuluma ngama ARvs kanye nama regimens ayo.(IsiZulu) [the programme for everyone infected and affected by HIV. Today we are talking about drug classes and their regimens.

Thami Mthembu: Dokotela Majoro, yini kahle kahle i-regimen and yini futhi lama Klasis abakhuluma ngawo? (IsiZulu) [Dr Majoro, what is a ‘regimen’ and what are these classes they are talking about?]

Dr Trevor Majoro: Let me just go arrange these medications so we can understand them according to their categories in different groups. This is Zidovudine which is AZT and this is Tenofovir and this is Lamivudine which is 3TC, it’s same as this one and this is Stavudine is in the same category with AZT, this is Tenofovir same drug as this one, and this is 3TC here, and this is also 3TC. Basically that’s how they should look category one and this is category two. We don’t have category three under these nukes. These ones… okay we’ve got nothing under the Non-Nukes, you’re all taking Kaletra and it falls under the protease inhibitors which is category number five.

Dr Trevor Majoro: E-South Africa sinama regimens ayi two. Regimen one and 2. Ku regimen one kune regimen 1a and 1b. Ku regimen 1a sena two drugs from amanukes and one drug from amanon- nukes and amadrgs akhona kuma nukes yi d4T ne kanye ne 3TC. And then kuma non-nukes I drug esinayo ku 1a yi Efevirez or Stoctrine. K And then ku regimen 1b still sisane ne d4T ne 3Tc kuma nukes, and then kuma non-nukes which is the part ephakhathi nedawo where there is no drug now, the yi Nevirapine. Then klu regimen two sine AZT which is the nuke ddl which is alos the nuke and then iKaletra which is a protease inhibitor. So those are the regimens ezikhona. Now if you look at this table uzo realise ukuthi kuma non- nukes wethu akhunalutho. Meaning no one phakhathi kwenu othatha non nucleoside reverse transcriptase inhibitors. It means ukuthi possibly either somebody has develop severe side effects of ama non-nukes be it Efavirenz (Stoctrine) I mean or Nevirapine. Omhlambe people have developed resistance kuwo. Now we know ukuthi lama non-nukes lawa they are the first drugs to go in terms if resistance because resistance barrier yawo i-low. In other words khulula ukuthi a developer I resistance to ama-non-nukes which is Nevirapine or Stoctrine. Once you develop I resistance to Stoctrine automatically une resitance to Nevirapine because zine cross resistance. (IsiZulu) In South Africa we have two regimens: regimen one and two. In regimen one, we have regimen 1a and 1b. In regimen 1a, we have two nukes and one non-nukes. The nukes are d4T and 3TC, and we have Efavirenz (Stocrine) as non-nuke in regimen 1a. In regimen 1b, we still have d4T and 3TC as nukes, and in the non-nukes, where there’s nothing now, we have Nevirapine. In regimen two, we have two nukes: AZT, ddl and Kaletra, which is a protease inhibitor. So those are the regimens that we have. If you look at this table, you will realise that the nukes section is empty, meaning that no one amongst you is using a non-nuke. That means that either somebody has developed severe side effects of non-nukes, be it Efavirenz (Stocrine) or Nevirapine, or maybe they have developed resistance. We know that non-nukes are the first drugs to going terms of resistance because they have a low resistance barrier. It’s easy for someone to develop resistance to non-nukes, which is Nevirapine or Stocrine. And once you develop resistance to Stocrine, you are automatically resistant to Nevirapine because they have a cross resistance.] So once you loss one drug kuma non-nukes you have lost the other drug in terms of resistance, so you can’t use any of them.

Busisiwe Maqungo: Kutheni kubalulekile into yokuba nxa ufakwe ku regimen leyokuqala funeka uzame kangakho umane uhlale phaya ungakhawulezi udeloper iresistance kulama qciza akho?After leya klasi kuzayenzekhala ntoni? Because ekugqibeleni bazahamba, bahambe badeveloper iresistance naphaya. (IsiXhosa) [Why it is important to remain on regimen one, you must try by all means to remain on it and not develop resistance? What is going to happen after the second regimen? Because they are bound to develop resistance to it as well,] after that one what happens?

Dr Trevor Majoro: Kubalulekile ukuthi abantu abangaze babe kuma ARVs sibaqale nge regimen one whether is 1a or 1b. Ukubalukeka kwawo yikuthi baningi abantu abasebenzisa iregimen 1wherther a or b for iskhathi eside before bangaya kuregimen two. And nxa wokhona ukuhlala isikhathi eside ku regimen one lokho kusho ukuthi asanama options amaningi in future. Uma usukha kuregimen one uya ku regimen two like in a case esiyibona la lokho kusho ukuthi amaoptions sewaciphile. If ku developer I problem manje ngalama drugs ala, abawathathayo then bayakulento isiyibiza ukuthi yi salvage therapy. Salavage therapy isho ukuthi kudependa ku experience yeclinician ekunakhekhele. Umangabe lomuntu okhunakhekhele unolwazi noma unabantu abangamusiza ngo lwazi banga khona ukubona I combination a best for wena. We hope ukthi in future sizikhona ukebe sibe namanye amaoptions uyazi ukuthi kukhona kwamanye amacountries abantu bakhona basebenzise amaprotease inhibitors. So amaoptions esinawo kwi regimine two yi salvage therapy and possibilities of looking at other possible combination into the future engekho manje in this country. {IsiZulu} [It’s important to start people who have never been on ARVs on regimen one … Whether it’s 1A or 1B. It is important because many people stay on regimen one for a long time, before they go to regimen 2. If a person sticks to regimen one for a long time, that gives them options for the future. If you move from regimen one to regimen two, like in the case we have here, it means that your options are limited. If they develop any problem with the drugs they are now using, they will have to go to salvage therapy. Salvage therapy depends on the experience of the clinician. If the clinician has experience, or can get advice from other doctors, they can choose the best combination for the patient. We have that in future, we can have more options, because in other countries people use more than one protease inhibitor. The options we have from regimen two are salvage therapy, and the other combinations which are not yet available in this country.]

Shalom Ncala: [We will talk more about drug classes and regimens.] {Sesotho} Sizobuya kungekhudala no doctor Trevor Majoro ukuze asisize ukuchazulule lenkinga. {IsiZulu [We will be back shortly with Dr Majoro to help us unpack this problem.]

Shalom Ncala: Uhlelo lawonke umntu ongenwe futhi otithekayo kwi HIV. Namhlanje sikhuluma ngama ARvs kanye nama regimens ayo. ISiyayinqoba ilandela uMonwabisi Bikwana lapho ayogcwalisa khona isecelo se section 21 se Tenofovir. Udoctor Van Supsen ungudokotela kwa Monwabisi usetshela ngomithetho efanele ilandwele. Loyokufaka isicelo se section 21. {IsiZulu}

[Welcome back to the Siyayinqoba Beat It! support group,] the programme for everyone infected and affected by HIV. Today we’re talking about classes and regimens. Siyayinqoba followed Monwabisi Bikwana, filling in section 21 applications for Tenofovir. Dr Van Cupsen Monwabisi’s doctor tells us about the process of applying for section 21.]

Khayelitsha, Western Cape, Section 21 application for Tenofovir.

Monwabisi Bikwana: Igculaza okanye iHIV ndaye ndazifumanisa ukuba ndinayo, ndizifumanisa ngonyaka ka 2001. Ngalonyaka ke bendiphathwa kugula kwefever, ndimane ndifumane ifever iphinde ibuye iphele, iphine ibuye phele. Waze ke ugqirha ndandinaye ndisenaye nangoku udoctor Bam wandiyenza ukuba nde tester iHIV. Ndasiwa ke kuclinic eceda ke ngamanxiza ARVs ase Site B Ndabe ke ndicedwa ngu doctor Gilles owathi ke ndi qalise i-ARVs kodwa ke bekunyanzelike kuqala ukuba mandilinde ithuba lami. Ngabe ke ithuba lami ndilinikwa ngo April 2002. I first line yami ndanikwa ngu doctor Gilles kwaba 3TCNevirapine ne d4T. Ndawasebezisa ke amanxiza andugquba kodwa ke kwafumaniseka yokuba ndiyayifelisha I first line. {IsiXhosa} [The first time I found out that I am living with HIV was in 2001. I had a recurrent fever. My doctor Dr Bam suggested I test for HIV. I was referred to an ARV rollout site in Site B. I was assisted by Dr Gilles, who put me on ARVs, but I had to wait for a while. I eventually started on ARVs in April 2002. My first line regimen was 3TC, Nevirapine and d4T. I took them for a while but soon found that I was failing in the first line.]

Dr Gilles van Cupsen, Doctors without Borders, Khayelitsha: Your viral load has been high for a very long time now. And the first line regimen cannot be used anymore. You need to chance to a second line regimen.

Monwabisi Bikwana: What the second line regimen is?

Dr Gilles van Cupsen: Second line is other ARVs and they’re more powerful. One of them is Kaletra, and I will explain to you what it is. Another one is 3TC, and, because AZT and d4T don’t work for you anymore, we have to import a drug that is not registered in South Africa yet, which is Tenofovir.

Monwabisi Bikwana: Is it not going to be a problem that the drugs are going to be ordered in another country?

Dr Gilles van Cupsen: It’s called a Section 21. It’s an authorisation to the drug regulatory body in South Africa, because Tenofovir is not registered in South Africa. It is not a drug that is allowed to be used in SA without special authorisation. Tenofovir is actually a fantastic drug. Why? Because it has a very good safety profile, very little side-effects, no lactic acidosis reported. There is no peripheral neuropathy. Second advantage of Tenofovir – it’s one daily, one tablet, which is easier to take than twice daily tablets. And then the third advantage is that it has a very good resistance profile, which means if you put Tenovofir first line, and you fail your first line and you stay on that failing first line for some time, you’re not going to develop HIV strains, or very little, that are resistant to the second line, as you have with the current first and second line option. Thank you Monwabisi, the form is filled, that’s fine. Now, we have to, when I will give this form to the MSF office, they will send it to the MCC. We wait for the MCC to give an answer, if it’s authorised or not. Don’t worry, usually it’s authorised. And then we have to send the authorisation with a whole dossier to the United States to Gilead, which is the company that makes Tenofovir. And then we’ll have to wait till they send it to South Africa, which might take a couple of weeks definitely.

Monwabisi Bikwana: Sho!

Stavros Nicolaou Senior Executive, Aspen Pharmacare: Tenofovir was filed for registration with the Medicines Control Council by Aspen, roughly seven to eight months ago. It is on a fast track. What that means is that certain drugs, when they’re declared to be emergency drugs, such as this one, the Medicines Control Council has a fast-track process. We’ve been approved for fast track, and roughly the period for fast tracking is between 12 to 15 months in our experience. I’d say we’re pretty close to receiving registration with Tenofovir.

Dr Francesca Conradie, Senior Clinician, Wits: Once Tenofovir is registered, we’re going to need to change the national roll-out programme, which is going to involve, first of all, retraining the staff. It’s a different drug with a different side effects profile. We need to get that message out and we need to add some extra safety bloods to what we’re currently doing… I think, to pressurise the government, there are a number of activist organisations. The TAC is involved in also trying to expedite the registration of Tenofovir. The South African Clinicians Society, which is by the way the biggest collection of HIV clinicians in the world, is also advocating the movement of Tenofovir towards a registered drug.

Stavros Nicolaou: The benefit of having the product registered is, physicians, clinicians, other healthcare officials, will be able to prescribe and dispense this drug. So that is the benefit of registration.

Three weeks later

Doctor: Hi Monwabisi, have a seat. How are you?’

Monwabisi Bikwana: I’m feeling alright, I hope you’ve got some great news for me.

Doctor: Well, the good news is that your Tenofovir has arrived.

Monwabisi Bikwana: Ooh, at last, at last! I have been waiting for this Tenofovir for quite some time.

Doctor: Okay, your next date will be in one month’s time.

Monwabisi Bikwana: Yes, that’s very nice.

Doctor: And there’s nothing else that you need, so I’ll just take the folder back to reception when it’s done.

Monwabisi Bikwana: Okay, thanks!

Support group

Shalom Ncala: Kwenzakalani ku-public sector? Or yini into esifanele siyiyenze kuzokwazi sithole le Tenofovir lula? {IsiZulu} [How does it work in the public sector? Are we able to get Tenofovir, or what do we need to get Tenofovir easily?]

Dr Trevor Majoro: I problem ekona manje yikuthi u government has not yet given I permission yokuthi i-Tenofovir ingatholakala ku-public sector. But njengoba besilalele lapha ku insert ukuthi igroup le ye Aspen ye pharmaceutical I aplayele ukuthi yikhone ukuthi I didtrubutor in the country and mashilo ukuthi approve ukuthi ba fast track ukuthi ibe available. So siyathemba ukuthi izokhona ukuthi ibekhona , singajabula futhi ebekhona of ama advantages esiwashilo and lokho kunga siza kakhulu in terms of overcoming amareasoning ayenza abantu banga thathi ama ARVs manje because lama side effects esikhulume ngawo.{IsiZulu} [Government has not yet given permission for Tenofovir to be available in the public sector. As we heard form the insert, the pharmaceutical group, Aspen, has applied for rights to distribute Tenofovir. And they have approved fast availability. So we hope that it is going to be available soon. We will be happy if it can be because of its advantages, and that can overcome some of the reasons that cause people not to take ARVs because of side-effects. ]

Thami Mthembu: While umuntu leyo section 21 application sibonile ku insert, nina njengama health practitioners nanzani during that period? Mhlambe nimubeka ku treatment holiday noma khona okunye enikusebenzisayo to prolong I process kacane ukuthi akwazi ukuphila? {IsiZulu} [While the person is waiting for the section 21 application, what do you do, as health practitioners, during that period? Do you perhaps put the person on treatment holiday? Or are there any other means you employ to prolong the patient’s life?]

Dr Trevor Majoro: Kunama options esingawaladela. I think ukuthi kuzoyenzakhalani kuzo dependa ku clinical picture ye client, if somebody is clinical stable and immunology I CD4 count yabo I phezulu say above 200 and I viral load yabo is well suppressed or well undetectable I think what happens in the case is if u sebenzisa any other drug kungabeka umuntu esimeni esingekho sihle kuya nge drug a resistance kuyo. . It’s much better to substitute the offending drug, or le drug a developer I resttance kuyo with another drug. Maybe substitute d4T, and use AZT meantime or alternative if kune problem a category one type yama drugs, is better to stop all the drugs because ama chances we resistance nacane. I ressitance I developer kalula if you remove one or two drugs and then allow ireduction to I pressure aplaye on the virus. But if you remove everthing ngesekhathi esiyi one resistance does not become e much of a problem. {IsiZulu} [There are other options, but it all depends on the client’s clinical picture. If the client is clinically stable, which a CD4 count of above 200, and the viral load is well suppressed or undetectable, I think what happens in that case is, if you feel like using any other drug, that can put the patient in danger, like continuing with a drug that a person is resistant to. It’s much better to substitute the offending drug, or the drug the patient has developed resistance to with another drug. Maybe substitute d4T, and use AZT meantime or alternatively, if you’re got a problem with category one type of drugs, it’s better to stop all the drugs. Because once you stop all the drugs, chances of resistance decrease. Resistance develops easier if you remove one or two drugs and allow reduction on the pressure that you apply on the virus. But if you remove everything in category one, resistance does not become much of a problem. ]

Shalom Ncala: Namhlanje sifunde ukuthi kukhona isidingo sokuba na ma ARVs amaningi anemiphumela emibi emibalwa. Abantu abanemiphumela imibi, abaphuza I AZT noma id4T kufanele bathole I Tenofovir. Asikhaleni saloko. UVuyani, uNokhwezi kanye nami sonke isingeni sesibili regimen kumanje. Kuzoyenzakhalani kithi if si funa usifuna umunqa wesithathu? Okwamanje awoku umunqa wesithathu we regimen okhona eMningizinu Afrika. Kumele siqale ukuphoqelele uhulumeni wethu avumele ukubhalisa loma ARVs asemunqeni wesithathu. Ukubhalisa waloma ARVs afana ne Tenovir kumele kuyenzekhe ngokushehsa. Siyasijabulela zonke izincwadi zenu enizuthumelayo sicela nihlale nizithumela njalo. Siyayijabulela imibono yenu nemi buzo yenu ngakho ke sicela kumniningwane eniyibona ngezansi. Sithemba ukuthi ulijabulele uhlelo lwethu futhi unomoya wo Siyayinqoba sisinke singayohlula. Hlangana nathi futhi evilini elizayo eqenjweni leSiyayinqoba Beat It! Kuze kube yileso sikhathi hlala unephilo futhi unethemba.Salani kahle.{IsiZulu} [Today we’ve learnt that there is a need to have more ARVs that have fewer side-effects. People with bad side-effects from AZT and d4T should get Tenofovir. Vuyani, Nokhwezi and myself are on the second line at the moment. What will happen when we need a third line? At the moment, there is no third line regimen available in South Africa. We must convince our government to allow these third line regimens. The registration of ARVs such as Tenofovir needs to be quicker. We really appreciated your letters, so please write to us at the addresses on your screen now. We hope that you enjoyed the show and feeling the Siyayinqoba spirit, that together we can Beat It! Join us again next week on the Siyayinqoba Beat It! support group. Until then, stay healthy, stay positive. Goodbye.

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