The public health approach to HIV treatment, in which a limited number of drug combinations is used for all patients in South African programs, works just as well as the highly individualized approach to drug selection used in Switzerland, according to new research.
Researchers based at University of Bern, Switzerland and University of Cape Town, South Africa, analyzed data collected since 2001 from more than 2,000 patients enrolled in HIV treatment programs in two townships (Gugulethu and Khayelitsha) in Cape Town, South Africa, and from more than 1,000 patients enrolled in the Swiss HIV Cohort Study, a nationwide study of HIV-infected people.
Currently, approximately 3 million people with HIV in low- and middle-income countries are receiving antiretroviral therapy. The majority of treated individuals are in sub-Saharan Africa, where only about 50,000 people were being treated as recently as 5 years ago. This rapid scale-up has raised questions of whether the World Health Organization's standardized approach to treatment selection and clinical monitoring can meet with the same success as "customized" approaches used in high-income countries.
This study found the programmatic and individualized approaches to be equally successful -- provided that treatment is begun early enough. The patients in South Africa started their treatment for HIV infection with one of four first-line therapies, and about a quarter changed to a second-line therapy during the study. By contrast, 36 first-line regimens were used in Switzerland, where half the patients changed to a different regimen. Despite these differences, the level of HIV in blood was greatly reduced within a year in virtually all the patients and viral rebound (an increase in viral levels following initially effective treatment) developed within 2 years in a quarter of the patients in both countries.
However, more patients died in South Africa than in Switzerland, particularly during the first 3 months of therapy. According to the researchers, this difference likely reflects the fact that patients in South Africa were more likely than patients in Switzerland to have advanced AIDS prior to starting treatment.
These findings support the continued rollout of the public-health approach to HIV treatment in resource-poor countries, and raise the possibility that a more standardized approach could be taken in developed countries without compromising treatment effectiveness. The higher mortality in South Africa compared to Switzerland suggests that many HIV-infected patients in resource-limited countries would benefit from earlier initiation of therapy.
- Keiser O, Orrell C, Egger M, Wood R, Brinkhof MWG, et al. Public-Health and Individual Approaches to Antiretroviral Therapy: Township South Africa and Switzerland Compared. PLoS Medicine, 2008; 5 (7): e148 DOI: 10.1371/journal.pmed.0050148
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