Treating HIV in Asia: Lessons from amfAR's TREAT Asia Program
By Jeffrey Laurence, M.D.
February 21, 2007—The World Health Organization’s ambitious “3 by 5” initiative, to put three million people from poor and middle-income nations on combination anti-HIV therapies by 2005, failed to meet even half of its goal. But it established critical momentum, inciting multiple governmental and private donors to strive to do better. PEPFAR, the President's Emergency Plan for AIDS Relief, for example, now promises two million additional people on anti-HIV drugs and ten million more in some form of HIV care by 2008. But there are key problems with these plans that could have devastating effects over the long term unless addressed now. A report from amfAR's TREAT Asia program, published in the January 2007 issue of HIV Medicine, illustrates these concerns.
amfAR has established a collaborative group of sites in the Asia-Pacific region—currently 15 sites from Cambodia and India to Singapore and Japan—known as TAHOD, the TREAT Asia HIV Observational Database. For the recently published study, each of 12 sites recruited 200 HIV-positive patients. From this database, the amfAR-funded researchers gathered information on patients taking the most popular combination of anti-HIV drugs currently in use in Asia, d4T/3TC/NVP (stavudine, lamivudine, and nevirapine). These medications are common because they are relatively inexpensive—they are non-brand name “generic” drugs—and come in a convenient fixed-dose form. But they also have many disadvantages. And knowledge as to how well these drugs are tolerated and maintained in the “real world” of everyday patient care in resource-poor settings is essential to predicting the success of large-scale AIDS treatment programs.
Indeed, almost one-third of the patients surveyed stopped taking the drugs d4T and 3TC, most within a year. Side effects were the major reason for dropping out, the top two being lipodystrophy—the often disfiguring changes in body fat known to be a key problem with d4T—and liver disease. Even more discouraging was the fact that after stopping their first HIV treatment regimen, two in five patients failed to turn to any new HIV therapy.
While anti-HIV drugs do work—the vast majority of patients changing or stopping treatment in the TREAT Asia study did so because of drug side effects, not clinical failure—the lack of alternative treatments for many of these patients suggests that the emergence and evolution of drug-resistant strains will grow, and that life-prolonging effects of treatment will be denied. Attempts at a “one-combination-fits-all policy is potentially going to deprive a substantial number of patients of effective long-term therapy,” the HIV Medicine report concluded.
Twelve years ago, when combination treatments for HIV were first introduced into the resource-rich world, many argued that lack of sophisticated health infrastructures and the inability to test for T cell counts and viral loads would preclude effective therapy in resource-poor areas. Findings from amfAR's TREAT Asia program and other surveys show that such limitations do not necessarily impede the use of potent anti-HIV drugs. But, as highlighted by the report, we must provide more potent, alternative drugs with fewer side effects, now readily available in resource-rich countries, to these regions.
Dr. Laurence is amfAR’s Senior Scientific Consultant.