Eighth International Congress on Drug Therapy in HIV Infection Glasgow, UK - 12-16 November 2006

Int Cong Drug Therapy HIV 2006 Nov 12-16;8:Abstract No. PL3.6

Charles Gilks
Antiretroviral Treatment and HIV Care Unit, WHO, Geneva, Switzerland

PURPOSE OF THE STUDY: The main donors are all committed to (as close as possible) universal access to ART by 2010. To come close to this noble goal, major challenges and constraints will have to be identified and overcome:

• Identifying those in need: For infants who have become infected despite PMTCT, diagnosis is a challenge: dried blood spots collected from heel-pricks and sent to regional centres is one solution until POC technology is available. Starting at the right time remains a constraint with very limited access to CD4 technology; clinical staging will remain predominant. We still do not know when it is optimal to start.

• What to use: there is now consensus on a simple and standard public health approach to ART using dual NRTI with NNRTI first-line and reserving boosted PIs for second-line. But is this the optimal use of the three orally available drug classes? Drug prices have dropped dramatically for adult first-line with consensus on what to produce and a market-place emerging. This is not the case for paediatric ART and adult second-line. NNRTIs are toxic and have significant drug-drug interactions – is there any role for the “simplification strategy”?

• Ensuring adherence: Transforming HIV to a chronic disease is challenging, especially where most systems are not set up for long-term care. Patient preparedness, delivery close to home by nurses and community workers, individual patient education and community engagement are critical. For those who run into problems, referral mechanisms, supervision and mentoring has to be set up and implemented.

• When to switch: Failure can be defined clinically, immunologically or virologically; so far we have no clear consensus on the different parameters. Using clinical monitoring alone, most patients will fail with significant resistance – what impact this will have on second-line response is not well defined. Strategies to reduce and monitor the appearance and spread of resistance are agreed. However, ways to minimise transmission of resistant (or wild-type) virus from clients in care and on ARVs are not well developed to date.

• Failure of second-line: Although some groups are talking about “third-line”, there is currently no provision of this in a public health approach. What should the long-term strategy be without an affordable, potent, orally available class of drug?
  

• A capacitated health system: Overhanging all these challenges in many high-HIV burden countries is the endemic crisis in the health system. Unless this is solved in the medium and long-term, ART roll-out out will fail beyond a few privileged groups and sites where staff and infrastructure exist. Various initiatives are under way; already responses like task-shifting, wider use of nurses to initiate and monitor ART, and use of very simple protocols are in place. Programme data at the population level indicate that good results are achieved. Can this be scaled up? Time will tell.
  

Plenary Session: New Challenges in Providing ART [IAS Session]

2006-11-12
PL3.6

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