Abstract #3738  -  Strengthening the monitoring of antiretroviral therapy for HiV infected people in resource limited settings
Authors:   Presenting Author:   Dr David Dalmau - ad
Additional Authors:
Aim: More than 6,5 million patients worldwide are receiving antiretroviral therapy (ART) for HIV, with the majority of those now coming from resource limited settings (RLS). Despite earlier doubts, evidence shows that even in countries with very limited resources, well designed ART programs have shown effectiveness equal to that seen in clinical cohorts in USA and Europe using similar regimens. However, current expansion of ART therapy for HIV in RLS brings a series of fresh challenges particularly in relation to the emergence of drug resistance. It raises questions such as when to switch therapies, how to deal with the long-term consequences of virological failure after the first ART strategy or what second line ART to choose. Time since start of ART scale-up in a geographic area has been found to be an independent risk factor of primary HIV Drug Resistance, with an estimated risk increase of 38% (range 26% to 41% in sensitivity analysis) for each additional year.
Method / Issue: Several studies in developing countries have shown that continuation of a failing regimen is associated with more complex mutation patterns. The number and pattern of resistance mutations may depend on the exact components of the regimen, HIV-1 subtype and the duration of failure. The accumulation of resistance mutations will confer difficulties to find cost-effective subsequent treatment regimens, especially in settings with limited second line options and where people will still need decades of therapy. Failing first-line treatments in RLS will put an increased number of people on second-line ART which result in costs over six times higher (in drug costs alone) than first-line ART. The management of ART requires laboratory monitoring in the form of viral load testing which serves to guide clinical decisions on how to optimize the duration of the first-line treatment regimen and on when to switch to second line treatment, thus minimizing the impact of ART resistance mutations on treatment. Additionally, viral load monitoring avoids the additional costs associated with unnecessary switches to more expensive second-line regimens in patients without real virological failure. However, it has been argued that scaling up antiretroviral therapy in RLS requires more simplified approaches. As a result many ART programs have minimized the resources devoted to laboratory monitoring in an effort to accelerate widespread availability of HIV treatment.
Results / Comments: Here we argue that this policy is shortsighted and that cost effective HIV care in RLS cannot be provided without appropriate viral load monitoring. As noted, the opposite is true: continuous increase of HIV-infected people receiving ART increases the need to detect cases in which first-line treatment has failed. Moreover, technologies to determine the viral load have becoming much simpler, and laboratory costs have decreased significantly. Additional public health benefits of viral load monitoring include its potential role as an operational support tool for improving adherence, a reduced incidence of opportunistic infections and a reduced HIV transmission by limiting the number of persons with no suppressed HIV replication.
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