15th Conference on Retroviruses and Opportunistic Infections Boston, Massachusetts - February 3-6, 2008

Conf Retrovir Opportunistic Infect 2008 Feb 3-6;15: (abstract no. 4)

Gary Maartens
Univ of Cape Town, South Africa

BACKGROUND: In Africa there are still many more new HIV infections than people placed on ART, and UNAIDS point to a widening funding gap for ART programs. Antiretroviral scale-up clearly still faces major challenges. However, considerable experience has been gained as many African ART roll-out programs have been operating for longer than 5 years, and 1.34 million people were receiving ART in 2006. Adherence rates have been high. Outcomes are generally excellent, apart from a high rate of early deaths, but a number of key issues have arisen with the maturing roll-out process. Long-running programs show that ART is being initiated with higher CD4 counts resulting in fewer deaths, but loss to follow-up has increased as clinics approach capacity. Human resources in Africa have emerged as a major concern for ART programs, with ongoing losses of health care personnel to industrialized countries. Greater use of public–private partnerships should be considered. Given that most African countries rely heavily on donor-funded programs, a key question is how sustainable is philanthropy?

CONCLUSIONS: The World Health Organization’s 2006 revised guidelines allow for earlier initiation of ART, largely based on symptomatic disease. Initiating ART based on a CD4 threshold of 350 should be considered for pregnant women, but will be unlikely to affect access to ART for other patients. Most countries rely on generic antiretrovirals with stavudine (d4T) in the first-line regimen, but d4T toxicity is increased in women and obese patients, which is common in urban Africa. Lower doses or avoiding d4T in obesity are strategies that may reduce toxicity. Tenofovir is a safer alternative, however it is currently considerably more expensive. Monitoring of ART is often done clinically or with CD4 counts, which is likely to result in switching to second-line regimens after prolonged virologic failure, with the risk of acquiring multiple nucleoside analog mutations. Fortunately second-line boosted protease inhibitor regimens are robust. More data are needed on using ART with tuberculosis, including optimal timing and regimens for use with rifampicin-based antitubercular therapy. There is as yet no pressing need for salvage ART.

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2008-02-03
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