Thursday 31 July 2008

Safe fasting

We're now just a month away from the Muslim fasting month of Ramadhan. This usually brings a slew of questions about taking meds while fasting. I have to be a bit careful about discussing this: at a recent training session, one participant hailed from Aceh, a very conservative Muslim area. He became quite angry with me as a bule (foreigner, literally with white skin) pontificating about what he felt was purely a religious matter.

Hopefully the problem of taking ARVs during Ramadhan will disappear for most in the next couple of years, as once-daily regimens become available here. But at the moment, almost everyone is taking meds on a 12-hourly basis. As I've noted before, we do try to encourage them to see this 12-hour interval as important.

But during Ramadhan, those fasting should not eat or drink between dawn and dusk. In Indonesia, this means an interval of around 14-15 hours. If they join the fast, and take their meds at the pre-dawn meal (sahur) and then again when they break the fast, will they risk developing resistance?

As far as we have been able to find out, there's been no trials of this, although the University of Indonesia has promised to do a study. So we're back with empirics. What I tell people is that if they don't want to take any risks, better to stick to their normal schedule, and accept any sanctions due - my understanding is that there are rules regarding this. But many have never since their youth missed a day fasting during Ramadhan, and the feel it very important to join the fast. For those, we say that the first-line regimens in Indonesia are pretty forgiving, and they will probably be OK, particularly with the blessings of God.

Actually, to me the greatest risk is not during the fasting month, when the routine is clearly defined by sahur and fast-breaking, but returning to their 12-hour schedule when the fasting month is over. To make this worse, as many will know, the post-Ramadhan holiday (Lebaran) in Indonesia is characterised by a return to the village, to the family. The journey often takes 24 hours or more - plenty of opportunities for forgetting the doses. Then at home, probably many family members are not aware of their HIV-status, so they must take the drugs surreptitiously in the midst of the celebrations. Again, difficult to remember. And of course, once returned to the city, the previous routine has been totally lost, and must be recovered. A real risk...

We really do need more forgiving, once-daily meds.

Babé

No comments: