In the era of World Health Organization guidelines recommending immediate antiretroviral treatment for people with HIV before the disease progresses, the reality in sub-Saharan Africa remains that up to 25 percent of patients who show up at clinics show up with extremely advanced illness, and that about 10 percent of them die soon after starting treatment.
Countering that is another reality, or in this case, REALITY — the Reduction of Early Mortality in HIV-Infected Adults and Children Starting Antiretroviral Therapy trial — that has identified one way to improve the odds for those patients. That answer — provision of a combination of preventive medicines targeting the most common dangerous infections among people with advanced HIV — can be supplied at low cost and at local clinics, according to a report in the New England Journal of Medicine. The authors note challenges to using the approach that included the possibilities of toxic effects and the development of resistance to the medicines, as well as the chance that adding more pills to the mix for people starting antiretroviral treatment regimens could make adhering to treatment harder for patients. But, researchers found among more than 1800 patients receiving treatment in Uganda, Zimbabwe, Malawi and Kenya, the combination of preventive medicines improved patients’ odds of surviving the next six months by 27 percent, and of living to see out a year following the beginning of their treatment by 24 percent, without toxic side effects, or reduced adherence to their treatment regimens. It significantly lowered rates of hospitalization and of new cases of tuberculosis and other infections.
While further studies could weigh the value of each preventive infection-fighting drug used in the combination to determine if some could be left out, the authors write that the benefits of the approach should be balanced against concerns of antimicrobial resistance. The cost of the combination of medicines they write, ranged from $8 to $34 across the countries where the trial took place, highlighting the importance of all countries being able to get drugs at the lowest prices. While the study summarized here did not include findings on lowered death rates after 48 weeks, looking at those benefits would “further increase the value-for-money” of the intervention.