Scaling Up Treatment for the Global AIDS Pandemic Challenges and Opportunities (2005) / Chapter Skim
Currently Skimming:
3 Lessons Learned
3 Lessons Learned
Pages 62-88
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From page 62... ...
Thus it is essential that the many lessons learned about the causes and implications of treatment success, treatment failure, and drug resistance in the developed and developing worlds guide ART scale-up programs. While the successes achieved in more resource-constrained settings may have occurred on a small scale, they, too, can provide invaluable lessons for the scale-up of treatment to the millions in need now and in the future.
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From page 63... ...
Overview of Resistance Drug resistance can render treatment ineffective for individual patients and has implications for the treatment of whole populations should they receive a high burden of transmitted drug-resistant virus. Resistance to HIV drugs arises in the presence of incomplete suppression of viral replication in the face of the selective pressure of drug treatment.
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From page 64... ...
. As discussed above, ineffective regimens that do not completely suppress viral replication will lead to resistant virus, and the use of sequential mono or dual therapy is no longer recommended because of its now-recognized association with the development of a high rate of drug resistance (Deeks, 2003; Hirsch et al., 1998, 2000, 2003; Leigh Brown et al., 2003)
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From page 65... ...
· Prescription of ineffective combination of drugs · Inadequate clinical follow-up SOURCE: Deeks, 2003. Resistance to Antiretroviral Drugs and Their Classes As noted above, drug resistance has been found for all classes of drugs available for treatment of HIV/AIDS (Clavel and Hance, 2004)
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From page 66... ...
Nevirapine Resistance: Implications for Mother, Child, and the Pandemic While single-dose nevirapine may be a cost-effective and simple regimen for preventing HIV transmission from mother to child in resourceconstrained settings, concerns regarding nevirapine resistance have arisen
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From page 67... ...
. Another factor to consider is the consequence of the emergence of nevirapine-resistant virus among different HIV subtypes, since the pattern of nevirapine-resistance mutations varies among subtypes.
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From page 68... ...
the future transmission rate of drug-resistant strains of HIV, and (3) the cumulative number of HIV infections prevented over time by widespread use of ART.
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From page 69... ...
, increased risky behaviors, higher levels of acquired resistance, and increased use of ineffective treatment regimens (i.e., those that do not adequately suppress viral replication)
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From page 70... ...
As emphasized in this chapter, one reason for failure that is of particular concern as planning occurs for wide-scale introduction of ART into resource-constrained settings is the emergence of drug resistance. The emergence of drug resistance is a concern mainly for the individual patient being treated, but also has implications for the durability of standard treatment regimens for the population as a whole.
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From page 71... ...
In part this is because only a small fraction of the 40 million people worldwide infected with HIV will actually be exposed to ART in the next several years; thus, HIV transmission will be largely from persons with susceptible virus. Although there are very limited data on the prevalence of resistant viral strains, even in the United States, one recent South African study showed that among 37 drug-näive HIV-positive women screened in an antenatal clinic, none had any of 23 mutations known to be associated with ARV resistance, suggesting that even after 3 years of ART, resistance is still low to undetectable at the level of untreated patients (Pillay et al., 2002)
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From page 72... ...
Recommendation 3-1. For individual patients about to embark on therapy, general clinical screening for resistance to antiretroviral drugs is not recommended at this time for two reasons: because the preva lence of resistance in HIV-infected individuals not previously exposed to antiretroviral therapy is expected to be undetectable or low, and because the proportion of total persons with HIV who are receiving therapy in a given country will also be relatively small in the short term.
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From page 73... ...
LEARNING BY DOING: SCALE-UP AROUND THE WORLD This section reviews lessons learned from ART scale-up in five countries: Brazil, Haiti, South Africa, Nigeria, and Uganda. Brazil Brazil, with a per capita income of about US$3,000, is much less resource-constrained than most of sub-Saharan Africa, the Caribbean, and other countries being targeted for current ART scale-up programs, and its national HIV prevalence rate is much lower.
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From page 74... ...
The Brazilian government acknowledged the problem, and citizens participated in committees designing the country's response. Following passage of the law guaranteeing free, universal ART in 1996, an independent advisory committee established national treatment guidelines and criteria, and the treatment program was integrated into the existing health care infrastructure.
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From page 75... ...
. In rural Haiti, the HIV Equity Initiative was established in 1998 with assistance from the Boston-based Partners in Health, which is affiliated with Harvard Medical School (WHO, 2003a)
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From page 76... ...
. The HIV Equity Initiative in Haiti harnessed the capacity of human infrastructure and trained a cadre of community health workers in the administration and follow-up of ART.
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From page 77... ...
They also were trained in recognizing complications of the disease and its therapies; as complications arose, patients would be referred back to the Clinique Bon Sauveur for a more skilled evaluation. Routinely, however, patients treated through the HIV Equity Initiative were followed up in clinic on a monthly basis.
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From page 78... ...
Summary GHESKIO and the HIV Equity Initiative provide ART to over 1,600 people living in resource-constrained settings and serve as helpful examples for ART scale-up. As the result of two national conferences attended by representatives from the Haitian Ministry of Health, U.S.
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From page 79... ...
All of MSF's ART programs, the first of which was initiat ed in 2001, are pilot projects designed to demonstrate the efficacy and feasibility of ART in resource-poor settings. Currently there are 42 ART programs in 19 coun tries throughout Africa, Asia, Latin America, and the former Soviet Union serving some 11,000 people on ART.
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From page 80... ...
In the case of the latter two drugs, the decision on which to use takes into account whether a patient is also being treated for tuberculosis, has indications of abnormal liver function, or is pregnant. Patients receive clinical assessments either weekly or biweekly for the first 2 months of treatment, after which they are evaluated on a monthly basis.
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From page 81... ...
Médecins sans Frontières played a pivotal role in guiding the program and procuring affordable ARVs, and the Treatment Action Campaign, a grassroots advocacy group, was instrumental in mobilizing the community to be aware of HIV as a political issue and pressuring the government to address it. The latter group has also established education programs to combat the stigma and discrimination associated with the disease and to promote its prevention and treatment.
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From page 82... ...
. In an effort to improve access to ART in resource-constrained settings, UNAIDS launched a pilot project-the HIV Drug Access Initiative -- to introduce structured therapy programs in four countries: Uganda, Cote d'Ivoire, Chile, and Vietnam (Katzenstein et al., 2003)
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From page 83... ...
There are two primary suppliers of ARVs in Uganda: the Joint Clinical Research Centre and Medical Access Uganda Limited. The latter organization was established under the UNAIDS Drug Access Initiative as a not-forprofit company that would procure drugs at reduced cost from participating pharmaceutical companies and then sell these drugs to treatment centers accredited by Uganda's National Advisory Board (WHO, 2003c)
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From page 84... ...
· In the HAART era, 10 percent of new HIV infections are due to resistant virus strains. REFERENCES Barreiro P, Garcia-Benayas T, Soriano V, Gallant J
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From page 85... ...
2001b. Community-based treatment of advanced HIV disease: Introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy)
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From page 86... ...
2003. Antiretroviral drug resistance testing in adults infected with human immunodeficiency virus type 1: 2003 recommendations of an International AIDS Society-USA panel.
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From page 87... ...
2003. Adherence is not a barrier to successful antiretroviral therapy in South Africa AIDS 17(9)
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From page 88... ...
2003. Development of phenotypic and genotypic resistance to antiretroviral therapy in the UNAIDS HIV Drug Access Initiative -- Uganda.
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