News Article
October 9, 2009
More HIV-Infected Individuals in Developing Countries Now Have Access to Antiretroviral Treatment
Duke Global Health Institute Associate Director of Research John Bartlett and John F. Shao with Tumaini University in Moshi, Tanzania co-authored this article, which was published in the October 2009 issue of The Lancet.
Successes, challenges, and limitations of current antiretroviral therapy in low-income and middle-income countries
As a result of the scale-up of antiretroviral treatment (ART) programmes and substantial financial support worldwide, an increasing number of HIV-infected individuals in low-income and middle-income countries (LIMCs) now have access to ART. Despite this progress, important questions remain on the best use of ART and how patients should be maintained on a successful regimen. This Review addresses some of the issues faced by those managing the epidemic in LMICs, including when to start treatment, choice of first-line ART, and when to switch regimens. Although the first priority must be continued expansion of access to ART, there should be a move towards starting ART earlier to treat individuals before they reach advanced stages of disease, to reduce early mortality, and to build support for improved monitoring of treatment failure. There is also a need for more randomised controlled studies to identify the long-term outcomes, cost-effectiveness of ART, and use of virological monitoring in LMICs.
Treatment for HIV in low-income and middle-income countries (LMICs) is at present driven by a public health approach, whereby the primary goal is to provide antiretroviral therapy (ART) to as broad a population as possible in settings in which individualised management of patients by specialised physicians is not feasible. As a result of several initiatives, the availability of ART in LMICs has increased substantially since 2003. The launch of the “3 by 5” (3 million by 2005) initiative by WHO, the Joint UN Programme on AIDS (UNAIDS) and the US President’s Emergency Plan for AIDS Relief (PEPFAR), has led to scale-up programmes in many LMICs and access to free treatment at an increased number of sites. As a result, WHO reported that nearly 1 million more people were receiving ART by the end of 2007 compared with 2006, and that the original “3 by 5” target had been met, albeit later than intended. Furthermore, the number of AIDS-related deaths worldwide decreased from 2.9 million in 2003 and 2006 to 2.1 million in 2007. These substantial initiatives, in combination with improved prevention efforts, have led to a stabilisation of the epidemic in many parts of the world. However, as the number of individuals meeting the criteria for receiving ART continues to rise, the enormous potential loss of life associated with a failure to provide ART to all who need it remains. A modelling study in South Africa has, for example, projected that a rapid-growth versus a zero-growth strategy for scaling up ART could lead to the prevention of 1.3 million deaths between 2007 and 2012, which would save an additional 200,000 lives compared to that achieved under the current projected timeline for moderate ART scale-up in South Africa.
Despite progress in the availability of ART in LMICs, WHO estimated in 2007 that only 27—34% of people in need of ART worldwide were receiving treatment. Knowledge of one’s HIV status is essential for effective management and treatment. Survey estimates from sub-Saharan Africa indicate that only 12—25% of people infected with HIV are aware of their status. Although this represents a substantial increase from a decade ago, most people infected with HIV in LMICs remain unaware that they are infected. This and other substantial barriers to ART, including economic, social, logistic, and human resource issues, must be aggressively addressed before the goal of increased HIV care is realised.