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TLD or… nothing? Sa HIV treatment sa Pinas, nakasanayan ang magtiis ka or magdusa ka

Among others, nevirapine caused skin breakout, while efavirenz made people have lucid dreams (and was noted to impact the bone). Dolutegravir is supposed to be better, but creatinine level spikes are now noticed. What’s the alternative provided by DOH and HIV treatment hubs (or meron nga ba)?

Kamakailan lang, may isang Filipino with HIV na nagsabi sa amin (Recently, a Filipino with HIV told us) that the doctor attending him noticed a creatinine level spike since he started using the antiretroviral (ARV) combination of TLD (tenofovir, lamivudine, dolutegravir), which replaced TLE (tenofovir, lamivudine, efavirenz).

As FYI: high creatinine levels can occur when there are kidney-related issues, diabetic ketoacidosis or high blood pressure. And so it was suggested that he change his ARV again… back to TLE.

Three issues emerged for this PLHIV:

  1. The alternative combination recommended for him is supposedly scheduled to be phased out already, and so in this particular case, there’s a stockout/shortage of non-TLD ARVs;
  2. Still not much is known – or at least being made public knowledge – about the impacts of TLD in the Philippine setting (e.g. we have heard of stories, even complaints, about excessive weight gain, and yes, the zoom in creatinine level, and yet that’s all we have right now… stories); and
  3. Some doctors – including those working in HIV – thankfully already noted the creatinine level spikes among TLD users, and yet… the solution floated is NOT to deal with TLD itself, but just offer “solutions” when renal problems do finally occur among these PLHIVs.

As background:

The WHO has an alternative first-line regimen for infants and children – i.e. raltegravir (RAL)-based regimen, which is also what’s recommended for neonates.

In 2019, the recommendation stayed, though with Efavirenz (EFV) recommended as alternative first-line regimen for adults and adolescents with HIV and initiating ART.

Existing studies seem to highlight the benefits of using dolutegravir.

Not surprisingly, by mid-2019, 123 low- and middle-income countries (LMICs) already adopted or planned to switch to dolutegravir-based regimens for first line treatment in their national ART programs. As of 2021, it was estimated that at least 15 million PLHIVs were already using dolutegravir-based regimens that replaced efavirenz-containing regimens.

In the Philippines, TLD was approved for treatment-naive and treatment-experienced adolescents and adults living with HIV in September 2021.

Administrative Order No. 2022-0024 also emphasized the DOH’s stance on the use of dolutegravir as first-line regimen. In March, in fact, 100,707 bottles of dolutegravir were ordered, costing ₱ 10,759,535.88.

But same with all medicines, dolutegravir is NOT “perfect”, and can cause life-threatening side effects. And yes, serious liver problems are among the bad effects (yep… those creatinine level spikes among Filipino PLHIVs were definitely signifying/saying something).

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Alas, TLD rollout will continue; TLD will be the “norm”… until it isn’t.

Meaning, Filipinos living with HIV:

  • just have to “accept” TLD, and learn to live with using it;
  • have to start monitoring illnesses they may not have had before (e.g. creatinine level spikes); and
  • take extra steps due to possible ill effects of dolutegravir (e.g. hit the gym, check available renal care in your area, allocate extra funds if your kidney fails, et cetera).

Kung tutuusin, kung may nangyari sa iyo dahil sa (In reality, if something happens to you because of) TLD/dolutegravir, kargo dapat yan ng DOH at ng mga (it is supposed to be the responsibility of DOH and the) treatment hubs. But for now, nganga (we wait for nothing).

And so for now:

Demand that DOH – or even HIV treatment hubs – procure medicines for people who cannot, should not be using TLD/dolutegravir. Mga may sahod naman sila kaya kumilos naman sana (Those who receive salary for this should act accordingly).

While at it, DOH, treatment hubs, and HIV advocates and activists should start looking closely at how Filipinos with HIV accept/tolerate TLD/dolutegravir; start those studies now, and not wait until more people suffer. And then reconfigure national response according to the results of these studies.

In the end, if hiyang ka sa TLD (if TLD works for you), good for you. But for those whose medical condition/s are worsening, you shouldn’t have to just put up with it because the service providers tasked to look after you just can’t be bothered.

The founder of Outrage Magazine, Michael David dela Cruz Tan completed BA Communication Studies from University of Newcastle in NSW, Australia; and Master of Development Communication from the University of the Philippines-Open University. Conversant in Filipino Sign Language, Mick can: photograph, do artworks with mixed media, write (DUH!), shoot flicks, community organize, facilitate, lecture, and research (with pioneering studies under his belt). He authored "Being LGBT in Asia: Philippines Country Report", and "Red Lives" that creatively retells stories from the local HIV community. Among others, Mick received the Catholic Mass Media Awards in 2006 for Best Investigative Journalism, and Art that Matters - Literature from Amnesty Int'l Philippines in 2020. Cross his path is the dare (guarantee: It won't be boring).

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