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Expanded HIV Treatment in Resource-Poor Countries
Initial concerns that antiretroviral therapy would be less effective in resource-poor settings 
or that patients there would be less adherent appear to be unfounded.
Scale-up of antiretroviral therapy finally occurred this past year in many resource-poor countries. Thanks in large part to the WHO "3 by 5" initiative, the President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund on AIDS, TB, and Malaria, more people now have access to antiretroviral therapy than ever before. Several studies this year demonstrated the success of such efforts and also highlighted some of the remaining challenges.
Initial concerns about adherence in resource-poor countries appear to be unfounded, and, in fact, adherence might be better in Africa than in North America. A large meta-analysis of studies that evaluated adherence to antiretroviral medications among heterogeneous populations in sub-Saharan Africa and North America showed adequate adherence (
80%) in 77% of patients in Africa and 55% of those in North America (P<0.001) (ACC Sep 1 2006).
Virologic outcomes in resource-poor countries also appear to be good. Six months after treatment initiation, patients in low- and high-income countries had similar increases in CD4 counts (about 105 cells/mm3), and the two groups had similar proportions of patients achieving viral loads <500 copies/mL (about 75%). Unfortunately, patients in low-income countries were more likely to start therapy at a lower median CD4 count (108 vs. 234 cells/mm3) and to have a higher mortality rate, particularly in the first month of therapy. Notably, lower mortality rates were seen at sites that offered free access to treatment (ACC Apr 12 2006).
An additional concern has been that the most commonly used regimen for initial therapy in resource-poor countries is d4T + 3TC + nevirapine, a regimen that is no longer recommended for initial therapy in developed countries because of its toxicity. Not surprisingly, reports of neuropathy and rash emerged this year from resource-poor countries, with a substantial number of patients requiring substitution for toxicity, in particular, peripheral neuropathy. More concerning, however, were reports suggesting a higher-than-anticipated rate of lactic acidosis, particularly among women and among individuals weighing more than 75 kg (see ACC’s CROI meeting report).
In summary, access to antiretroviral therapy in resource-poor countries is becoming a reality, and the results are encouraging. Although not insurmountable, enormous challenges remain, including the ongoing severe shortage of economic and human resources and the limitations in drug availability because of delayed registration of new drugs. As the new year unfolds, we should continue to see the results of these massive public health interventions, and we hope that the lessons learned will be widely disseminated.
— Carlos del Rio, MD
Published in AIDS Clinical Care December 29, 2006