Assessing HIV ART in Rural Africa

Availability of antiretroviral therapy (ART) for people suffering with HIV/AIDS in developing African nations has increased in recent years. Still, many more HIV-infected individuals are in need. The critical focus of ART is to suppress viral replication while avoiding toxic side effects and drug resistance. One argument against increasing the availability of antiretroviral therapy in Africa is the concern that drug resistance could become widespread. Therefore, information on the status of current ART programs in Africa is critical to the planning of expanded services for HIV-infected patients. Early studies have yielded promising results, indicating an efficacy comparable to that of western and industrialized nations. However, evaluation of long-term efficacy in a rural setting has been limited. A study by Norwegian and Tanzanian researchers assessed the efficacy of antiretroviral therapy in HIV-infected patients receiving treatment in a rural Tanzanian hospital.

The study took place at Haydom Lutheran Hospital, in Tanzania, where antiretroviral therapy and patient care has been provided free of charge since October 2003. All 212 adults included in the study had completed at least six months of first-line antiretroviral therapy. Viral response was measured at a median time of 22.3 months following the start of antiretroviral therapy.

Characteristics of an effective program include free of charge care, intensive counseling and support, a close collaboration between clinical staff and community, home-based caregivers, and a constant, uninterrupted drug supply. The authors discovered a well- managed ART program at Haydom Lutheran Hospital.

Overall, viral suppression was observed in 88.2 percent of patients. Percentage of viral suppression was 94.8 percent after one year, 88 percent after two years, 75 percent after three years, and 87.5 percent after four years, although only a small number of patients had been receiving ART for three or four years. A genotyping assay found drug resistance mutations in 8.5 percent of patient samples. Antiretroviral therapy for more than three years was significantly associated with emerging drug resistance.

For patients who do develop drug resistance, a second-line of antiretrovirals may be required. Although drug resistance rates for first-line therapy are relatively low, the sheer number of Africans who may someday require second line therapy is potentially overwhelming. Findings from this study highlight the growing need to prepare for an influx of patients needing second-line therapy. The authors assert that expanded access to new antiretroviral drugs should be a priority in the global effort to control HIV/AIDS. There is also an urgent need for affordable, simplified assays that can be used in rural and limited-resource settings to measure viral load, so that treatment failure can be detected early on, and treatment options maximized.

Results from this study demonstrate that long-term viral suppression is possible even in remote areas of Africa. According to the authors, their findings demonstrate that the safety and efficacy of ART programs will not be diminished by expansion of services to patients. Data from this study may be helpful in efforts to predict drug resistance and future need for second-line antiretroviral therapy in rural Africa.

Virological efficacy and emergence of drug resistance in adults on antiretroviral treatment in rural Tanzania

BMC Infectious Diseases