Nearly one in ten people on antiretroviral treatment in rural Uganda report having shared medication, according to a population-based study presented at the 30th Conference on Retroviruses and Opportunistic Infections (CROI 2023) in Seattle. The research is the first population-based study to document the phenomenon in Africa and reveals new insights into whether this undermines or supports viral suppression.
Researchers sought to assess how many people had shared, given, bought or sold medication, with whom and if there was any association with viral suppression. To do this, they added queries around sharing antiretroviral therapy (ART) to questionnaires administered between 2018 and 2020 as part of the Rakai Community Cohort Study – a longitudinal survey of all consenting adults aged 15 to 49 across more than three dozen communities in south-central Uganda. Of the roughly 20,000 people who received the adapted questionnaire, 2852 people reported being on ART and were included in the final study sample. Women outnumbered men by a ratio of roughly two to one.
Of these participants, 266 (9.3%) reported ever having given, received, or – in the case of a few participants – bought ART. No one in the study reported selling the medication. Nearly 7% of the sample (193 people) said they had shared, received or bought ART in the last year.
Men (12.9%) were more likely to report having ever given or received ART than women (7.4%). Nearly one in five men between the ages of 25 and 35 admitted ever having exchanged treatment in this way.
Overall, most people who reported ever sharing ART said they engaged in both sharing and receiving the medication. Perhaps unsurprisingly, ART swapping was most likely to happen among those closest to participants: friends, spouses, and sexual partners.
Scientists then used a regression analysis to estimate whether sharing ART could be linked with being virally unsuppressed – a viral load of more than 40.
In this case, researchers found, it was not better to give than to receive.
People who supplied ART to others but never received it were twice as likely to be virally unsupressed than those who did not give or receive pills. Meanwhile, those who reported only receiving ART were more likely to be virally suppressed but this difference was not statistically significant.
Engaging in both the giving and receiving of medication did not increase the risk of being virally unsuppressed.
Sharing may actually be caring
The study did not report on reasons that drove people to parcel out ART, said Dr Caitlin Kennedy of Johns Hopkins University. However, follow-up questions on this are set to be included in the next survey as part of the Rakai Community Cohort Study. Previous research by the group found that local fisherfolk said they often shared pills among themselves if they were away fishing and unable to access the medication or if they had missed an appointment to refill their prescriptions.
Kennedy cautions that the latest research took place before Uganda switched to wide use of dolutegravir-based treatment, which is more forgiving of missed doses or before multi-month prescribing was broadly available. She says this and the introduction of long-acting injectable treatment may change patterns in ART sharing and associated viral suppression.
Meanwhile, she says, more research is needed to understand patterns in ART sharing and their impacts.
“We know that drug sharing is common,” she said. “Many [people] have prescription medication in their bathroom and closets at home waiting to be used by another person. However … there's been very little attention to drug sharing with ART.”
Quantitative studies on ART sharing globally are scant. One previous study conducted with female sex workers in South Africa found that 30% said they had ever shared pills.
Anecdotally, media and activists in countries like South Africa and Mozambique have reported ART sharing as a relatively common coping strategy, especially among migrants without easy access to health care and in communities experiencing drug stockouts.
Kennedy says that HIV programmes may benefit from including messaging on ART sharing within counselling. But she says there may be ways to harness these community coping strategies to improve adherence by, for instance, pairing some patients experiencing adherence challenges with a dedicated ART sharing partner.
“In our previous work this really did seem to be a strategy to improve adherence rather than a potentially negative thing,” she said. “It’s not yet clear in what ways this may be harmful or in what ways it might be helpful, at least for some patients.”
Ssekasanvu J et al. (Kennedy C presenting) ART sharing is common and associated with viremia: A population-based study in Uganda. Conference on Retroviruses and Opportunistic Infections, Seattle, abstract 206, 2023.