Triple-combination antiretroviral therapy in sub-Saharan Africa

Changes in stress, substance use and medication beliefs are associated with changes in adherence to HIV antiretroviral therapy

Stress, substance use and medication beliefs are among the most frequently cited barriers to HIV treatment adherence. This study used longitudinal techniques to examine the temporal relationship between these barriers and adherence among clients attending treatment adherence support programs in New York State. A total of 4,155 interview pairs were analyzed across three interview transitions. Multinomial models were constructed with four-category change-based independent variables (e.g., low stress at both interviews, low stress at interview 1 and high stress at interview 2, high stress at interview 1 and low stress at interview 2, high stress at both interviews) that predicted a similarly constructed four-category adherence change variable. Clients who reported positive changes in stress, substance use, or medication beliefs were more likely to change from being nonadherent to being adherent, while clients who reported negative changes were more likely to change from being adherent to being nonadherent. To improve or maintain adherence over time, strategies should be used that facilitate positive changes-and prevent negative changes-in stress, substance use, and medication beliefs.

Monotherapy in an era of combination therapy: is there a benefit? Experience in HIV-1-infected symptomatic South African children

We investigated the benefit of treating HIV-1-infected children with monotherapy where resources are limited. A retrospective chart review was undertaken in 12 symptomatic HIV-1-infected children treated with zidovudine or didanosine for at least 2 months. The main outcome measure was the effect on hospitalization. Anti-retroviral therapy was commenced in nine children because of prolonged or frequent hospitalization. Of three whose primary indication was bleeding secondary to thrombocytopenia, two had been hospitalized owing to severe intercurrent illness. One child had failure to thrive and another encephalopathy. Monotherapy was considered beneficial in all cases. Median duration of follow-up was 6.5 (2-31) months. The hospitalization index (days in hospital before and after start of monotherapy, divided by the total number of days before and after start of monotherapy) decreased from a median of 0.115 prior to therapy to 0.037 on therapy (p = 0.045, Wilcoxon matched pairs test). This study presents observational data supporting the investigation of monotherapy in resource-poor countries. It was associated with a significant reduction in hospitalization and appeared to result in clinical improvement. Prolonged or frequent hospitalization might represent a novel indication for use because in our setting the cost of hospitalization could potentially provide a 12-month-old infant with monotherapy for 2 months.

A randomized, double-blind trial of half versus standard dose of zidovudine plus zalcitabine in Thai HIV-1-infected patients (study HIV-NAT 001). HIV Netherlands Australia Thailand Research Collaboration

BACKGROUND

Triple combination antiretroviral therapy, recommended as standard of care, is unaffordable for much of the developing world.

OBJECTIVES

To establish whether half doses of zidovudine (AZT) and zalcitabine (ddC) are as effective as standard doses in a Thai population with lower body weight than Western populations and predominantly infected with HIV-1 subtype E.

METHODS

A group of 116 antiretroviral naive patients, with CD4 cell counts 100-500 x 10(6) cells/l, were randomized to: AZT 200 mg three times daily plus ddC 0.75 mg three times daily versus AZT 100 mg three times daily plus ddC 0.375 mg three times daily and followed-up regularly for 48 weeks.

RESULTS

The study enrolled 111 patients: 59 men and 52 women, body weight (mean +/- standard deviation) 56.4 +/- 12.3 kg, mean CD4 cell count 324 x 10(6) cells/l, mean HIV RNA 4.7 log10 copies/ml. There were no significant differences between the two groups. Twelve patients discontinued, including two deaths that were unrelated to study medication. No significant differences in adverse events were seen. Week 48 data for the standard dose and half dose arms, respectively, were mean CD4 cell count increases of 52 and 78 x 10(6) cells/l (P = 0.34), mean plasma HIV-1 RNA reduction of 1.4 and 1.1 log10 copies/ml (P = 0.10), HIV RNA of < 400 copies/ml in 52 and 20%[ (P = 0.001). Participants with higher than mean baseline CD8 cell counts (mean 1062 x 10(6) cells/l) showed greater decline in CD8 cells on standard doses. Further analysis showed improved reduction in HIV RNA (P < 0.0001) and in the percentage with undetectable HIV RNA (P = 0.0137) in the standard dose arm, corrected for baseline HIV RNA, which if < 4.75 log10 copies/ml significantly correlated with HIV RNA < 400 copies/ml at week 48.

CONCLUSION

At week 48, the proportion with HIV RNA < 400 copies/ml was significantly higher in the standard dose arm; lower baseline HIV RNA correlated with better HIV RNA outcome at 48 weeks. The arms did not differ in CD4 cell response but standard doses correlated with greater CD8 cell decline.

Breaking the silence: setting realistic priorities for AIDS control in less-developed countries

The AIDS pandemic is a human tragedy that is threatening development in the poorest countries. There is no cure or vaccine, but the tools to control the epidemic already exist. Nevertheless, there are few examples of national AIDS control programmes that have had an impact on the epidemic. We (an economist and a planner) attribute this to the reluctance of governments to confront AIDS and a failure to prioritise activities in the face of severe financial and administrative constraints. When implementation capacity is weak, expanding the number of activities may not improve programme effectiveness. Rather, by implementing a smaller, core set of the most cost-effective activities on a national scale, policymakers could have a huge effect on the overall epidemic in a sustained way and provide a foundation for expansion. We propose three core priorities for AIDS control in poor countries for prevention, treatment, and mitigation of the impact.

One world, one hope: the cost of providing antiretroviral therapy to all nations

OBJECTIVE

To estimate the potential direct cost of making triple combination antiretroviral therapy widely available to HIV-positive adults and children living in countries throughout the world.

METHODS

For each country, antiretroviral costs were obtained by multiplying the annual cost of triple antiretroviral therapy by the estimated number of HIV-positive persons accessing therapy. Per capita antiretroviral costs were computed by dividing the antiretroviral costs by the country's total population. The potential economic burden was calculated by dividing per capita antiretroviral costs by the gross national product (GNP) per capita. All values are expressed in 1997 US dollars.

RESULTS

The potential cost of making triple combination antiretroviral therapy available to HIV-positive individuals throughout the world was estimated to be over US$ 65.8 billion. By far the greatest financial burden was on sub-Saharan Africa. The highest per capita drug cost in this region would be incurred in the subregions of Southern Africa (US$ 149) followed by East Africa (US$ 116), Middle Africa (US$ 44), and West Africa (US$ 42). In the Americas, subregional data indicated the highest per capita drug cost would be in the Latin Caribbean (US$ 22), followed by the Caribbean (US$ 17), Andean Area (US$ 7), the Southern Cone (US$ 6), North America (US$ 6), and Central American Isthmus (US$ 5). In Asia and Europe the percentage of the GNP necessary to finance drug therapy was less than 1% in most countries examined.

CONCLUSION

Our results demonstrate that the cost of making combination antiretroviral therapy available worldwide would be exceedingly high, especially in countries with limited financial resources.