Remember when one of the objections to rolling out life-saving treatment to people living with HIV in developing countries was that lack of capacity to maintain treatment would lead to drug resistance on a massive scale? While that didn’t happen at the scary levels projected, the transmission of drug resistant strains of HIV continue to be a cause for concern while capacities to track drug resistance continue to fall short of needs. These are among the conclusions in a report on resistance to antiretroviral medicines, one of two World Health Organization publications released in advance of AIDS 2012 last week.
Together the documents, The Strategic Use of Antiretrovirals To Help End the HIV Epidemic, and WHO HIV Drug Resistance Report 2012 provide a snapshot of current knowledge around HIV treatment and prevention, and shed light on how science and implementation are likely to shape the guidelines the organization will release next year on the use of antiretroviral medicine for treatment and prevention of HIV.
The Strategic Use of Antiretrovirals, summarizing previous guidelines and research, acknowledges that while expanding treatment eligibility promises improved treatment and prevention outcomes, most countries in greatest needs of those improvements have yet to achieve universal access under current eligibility guidelines. Of course, it points out, all of those living with HIV not yet eligible for treatment will eventually become so. New policies, implementation efforts, and investments will be necessary to provide treatment under existing guidelines, let alone reap the benefits of treatment as prevention, the publication notes. Still, it suggests it can be done, pointing to the need for “more resolute efforts” to address structural barriers, improve access to testing, and building in community participation in the design of efforts. The “front-loading” of costs, it points out, will lead to long-term savings. And, for those of us who like pictures, it lays out the treatment scenarios so far, and what they could be, by eligibility numbers, projecting what taking full advantage of documented prevention benefits would mean.
At the same time, the WHO HIV Drug Resistance Report points to both the need and potential for implementers to strengthen programs by better tracking resistance to antiretroviral treatment and its causes.
Among WHO’s findings, through surveys and existing data:
- From 10 to 17 percent of patients previously unexposed to antiretrovirals in Europe, the United States, Japan and Australia have resistance to at least one drug;
- An estimated 6.6 percent of patients in low and middle income countries, previously unexposed to antiretrovirals showed signs of drug restistance;
- Surveys in low and middle-income countries found that among patients receiving antiretroviral treatment at 12 months, treatment failed for 9.4 percent. Data indicated that as many as 72.1 percent of those had HIV that was resistant to treatment, while treatment failed for the remaining 27.9 percent for other reasons, including treatment interruption. Some of those people, in the absence of capacities to test for drug resistance were switched to second-line treatments unecessarily.
The report concludes that program monitoring, including increased drug resistance monitoring will be necessary to prevent increases in HIV-related illnesses and deaths.