Time to act: global apathy towards HIV/AIDS is a crime against humanity

Challenges in the management of inflammatory bowel disease in sub-Saharan Africa

Inflammatory bowel disease (IBD) is generally considered a disease of high-income countries and is regarded as rare in sub-Saharan Africa. However, this assumption is almost certainly an underestimate, and the high burden of communicable diseases makes IBD in sub-Saharan Africa difficult to detect. Furthermore, some gastrointestinal infections can closely mimic IBD, contributing to delays in diagnosis and complicating therapeutic decision making. Constraints in endoscopic capacity alongside a scarcity of qualified diagnostic pathologists add to the difficulties. Implementing evidence-based guidelines recommended by international societies is challenging, mostly due to high costs and unavailability of medication. However, cost-effective approaches can still be implemented to manage IBD in sub-Saharan Africa as the predominant disease phenotype is mild-to-moderate ulcerative colitis, which often responds to treatment with basic medication. In this Series paper, we summarise the current management of IBD in sub-Saharan Africa and propose how it can be tailored to suit the epidemiological and socioeconomic specificities of the region. We also discuss measures required to address existing challenges, such as educating health-care workers about the diagnosis and management of IBD or improving endoscopic capacity.

Long-Term Changes of HIV/AIDS Incidence Rate in China and the U.S. Population From 1994 to 2019: A Join-Point and Age-Period-Cohort Analysis

Although HIV caused one of the worst epidemics since the late twentieth century, China and the U.S. has made substantial progress to control the spread of HIV/AIDS. However, the trends of HIV/AIDS incidence remain unclear in both countries. Therefore, this study aimed to highlight the long-term trends of HIV/AIDS incidence by gender in China and the U.S. population. The data were retrieved from the Global Burden of Disease (GBD) database since it would be helpful to assess the impact/role of designed policies in the control of HIV/AIDS incidence in both countries. The age-period-cohort (APC) model and join-point regression analysis were employed to estimate the age-period-cohort effect and the average annual percentage change (AAPC) on HIV incidence. Between 1994 and 2019, we observed an oscillating trend of the age-standardized incidence rate (ASIR) in China and an increasing ASIR trend in the U.S. Despite the period effect in China declined for both genders after peaked in 2004, the age effect in China grew among the young (from 15–19 to 25–29) and the old age groups (from 65–69 to 75–79). Similarly, the cohort effect increased among those born in the early (from 1924–1928 to 1934–1938) and the latest birth groups (from 1979–1983 to 2004–2009). In the case of the U.S., the age effect declined after it peaked in the 25–29 age group. People born in recent birth groups had a higher cohort effect than those born in early groups. In both countries, women were less infected by HIV than men. Therefore, besides effective strategies and awareness essential to protect the young age groups from HIV risk factors, the Chinese government should pay attention to the elderly who lacked family support and were exposed to HIV risk factors.

Effect of community antiretroviral therapy on treatment outcomes among stable antiretroviral therapy patients in Nigeria: A quasi experimental study

OBJECTIVES

This study evaluates the effect of Community Anti-retroviral Groups on Immunologic, Virologic and clinical outcomes of stable Antiretroviral Therapy patients in Nigeria.

METHOD

A cohort of 251 eligible adults (≥18 years) on first-line ART for at least 6 months with CD4 counts >200 cells/mm3 and viral load <1000 c/ml were devolved from 10 healthcare facilities to 51 community antiretroviral therapy groups. Baseline immunologic, virologic and clinical parameters were collected and community antiretroviral therapy group patients were followed up for a year after which Human Immunodeficiency Virus treatment outcomes at the baseline and a year after follow-up were compared using paired sample t-test. All the analyses were performed in STATA version 14.

RESULT

Out of the 251 stable antiretroviral therapy adults enrolled, 186 (75.3%) were female, 52 (22.7%) had attained post-secondary education and the mean age of participants was 38 years (SD: 9.5). Also, 66 (27.9%) were employed while 125 (52.7%) were self-employed and 46(19.41%) unemployed. 246 (98.0%) of the participants were retained in care. While there was no statistically significant change in the CD4 counts (456cells/mm3 vs 481cells/mm3 P-0.489) and Log10 viral load (3.54c/ml vs 3.69c/ml P-0.359) after one year of devolvement into the community, we observed a significant increase in body weight (60.8 vs 65, P-0.01).

CONCLUSION

This study demonstrates that community antiretroviral therapy has a potential of maintaining optimum treatment outcomes while improving adherence and retention, and reducing the burden of HIV treatment on the health facility. This study provides baseline information for further research and vital information for HIV program implementers planning to decentralize the management of stable antiretroviral therapy clients.

Pence, Putin, Mbeki and Their HIV/AIDS-Related Crimes Against Humanity: Call for Social Justice and Behavioral Science Advocacy

Indiana, a large rural state in the Midwestern United States, suffered the worst North American HIV outbreak among injection drug users in years. The Indiana state government under former Governor and current US Vice President Mike Pence fueled the HIV outbreak by prohibiting needle/syringe exchange and failed to take substantive action once the outbreak was identified. This failure in public health policy parallels the HIV epidemics driven by oppressive drug laws in current day Russia and is reminiscent of the anti-science AIDS denialism of 1999-2007 South Africa. The argument that Russian President Putin and former South African President Mbeki should be held accountable for their AIDS policies as crimes against humanity can be extended to Vice President Pence. Social and behavioral scientists have a responsibility to inform the public of HIV prevention realities and to advocate for evidence-based public health policies to prevent future outbreaks of HIV infection.

Shift in HIV/AIDS Epidemic in Southeastern China: A Longitudinal Study from 1987 to 2015

Objective: The aim of this study was to investigate the shift in the epidemiological features of HIV/AIDS during the last three decades in Fujian Province, southeastern China, so as to provide evidence for the development of novel HIV/AIDS control strategies. Methods: Data pertaining to the conventional surveillance, sentinel surveillance and epidemiological survey in Fujian Province during the period from 1987 to 2015 were collected. The epidemiological trends were described, and the subtypes of HIV strain were genotyped. In addition, the response to antiretroviral therapy was evaluated, and HIV genotypic resistance was assayed. Results: There was an increasing trend observed in the reported cases of HIV/AIDS in Fujian Province. From 1987 to the end of 2015, a total of 8651 HIV/AIDS cases were reported across the province, with totally 1557 deaths found. Among the total cases, the ratio of male/female cases was 3.7:1, which appeared to be an increasing trend; 77.1% cases were detected in young and middle-aged populations aged 19 to 50 years, however, the new HIV infections recently tended to occur in young people aged 15 to 18 years and in populations aged 50 years and older. Among all infected individuals, 49.3% were married, however, the percentage of unmarried cases increased from 6.67% before 1994 to 40.1% in 2015; 64.8% had junior high school education or lower, however, the proportion of HIV/AIDS cases with junior college education or above gradually increased from 6.5% in 2009 to 21.4% in 2015. The reported HIV/AIDS cases were predominantly found in coastal regions; however, a rapidly increasing trend was seen in the number of HIV/AIDS cases in inland regions, and the geographical variation of the cases gradually reduced. There were multiple routes of HIV transmission found in Fujian Province, and 94.2% infections were sexually transmitted, with a large increase in the percentage of male homosexual transmission. A variety of HIV-1 subtypes were genotyped in the province during the study period, and CRF01-AE and CRF07-BC intersubtype recombinant forms were predominant; however, a declining trend in the proportion of HIV-1 CRF01-AE recombinant virus and a significant rise in the proportion of HIV-1 CRF07-BC recombinant virus were observed. Over 90% HIV inhibition was found in all cases receiving antiretroviral therapy during the period from 2011 to 2015, indicating a low prevalence of HIV drug resistance. Conclusions: An increasing trend is still observed in the HIV/AIDS epidemics in Fujian Province, southeastern China. However, the epidemiological pattern of HIV/AIDS has recently changed in the province, and effective control interventions targeting the shift in the epidemiological features of HIV/AIDS should therefore be implemented to control the spread of the epidemic.

The Health of Peoples: Predicaments Facing a Reasoned Utopia

How might nations cooperate to improve the health of their most vulnerable peoples? There is, presently, no coherent political, social, or ethical framework to answer this question. What progress there is remains piecemeal. Despite a long-term strategy to 2015 enshrining health as part of the process of human development—the Millennium Development Goals—existing institutions are struggling to meet these challenges. The WHO is underfunded and its work in countries is weak. The World Bank is rich but remains unable to free itself from a neoliberal Washington consensus. New institutions—such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria—distort efforts to build a coordinated international strategy for global health. And major policy initiatives (e.g., the Commission on Macroeconomics and Health) lack political commitment to invest in health. In this article, the author traces the beginnings of an answer to the question of what might constitute a political (specifically, foreign policy) approach to improving the health of peoples. A normative model for defining a just health system is urgently required. The author uses the framework of international relations provided by John Rawls to devise a series of policy principles for the health of peoples.

Curing HIV: Moving Forward Faster

There is enormous enthusiasm in the scientific community for finding a cure for HIV. Although much remains to be discovered regarding the mechanisms of viral persistence and how it may be disrupted, some assumptions regarding the goals of a cure, applicability to target populations, and what is required of the assays we employ, may lead to missed opportunities and discoveries and hamper the discovery of a product that will safely cure tens of millions of HIV-infected people around the world. The field will benefit from an awareness and critical interrogation of assumptions that may be implicit in their scientific pursuits.

The history of antiretroviral therapy and of its implementation in resource-limited areas of the world

HIV/AIDS not only represents the most severe epidemic in modern times, but also the greatest public health challenge in history. The response of the scientific community has been impressive and in just a few years, turned an inevitably fatal disease into a chronic manageable although not yet curable condition. The development of antiretroviral therapy is not only the history of scientific advancements: it is the result of the passionate 'alliance' towards a common goal between researchers, doctors and nurses, pharmaceutical industries, regulators, public health officials and the community of HIV-infected patients, which is rather unique in the history of medicine. In addition, the rapid and progressive development of antiretroviral therapy has not only proven to be life-saving for many millions but has been instrumental in unveiling the inequities in access to health between rich and poor countries of the world. Optimal benefits indeed, are not accessible to all people living with HIV, with challenges to coverage and sustainability in low and middle income countries. This paper will review the progress made, starting from the initial despairing times, till the current battle towards universal access to treatment and care for all people living with HIV.

HIV treatment adherence, patient health literacy, and health care provider-patient communication: results from the 2010 AIDS Treatment for Life International Survey

BACKGROUND

Little is known about patients' health literacy regarding antiretroviral therapy (ART) adherence and drug resistance and patient-provider communication about these topics.

DESIGN AND METHODS

The AIDS Treatment for Life International Survey was a multicountry cross-sectional study (January-March 2010) including 2035 HIV-infected adults. A 40-minute interview was conducted using a standardized self-report adherence questionnaire.

RESULTS

Overall, 57% of patients reported a 30-day recall of 100% adherence (Latin America: 89%; Africa: 73% vs North America: 45% and Asia Pacific: 47%; P < .01). Overall, 18% identified HIV drug resistance as a "good thing" in North America (35%) and Africa (24%). Only 71% said their health care providers had offered practical recommendations about adherence, 62% of the patients in North America and 80% in Latin America and Africa.

CONCLUSIONS

Optimal ART adherence remains a challenge globally. There is a critical need to improve patient-provider communication about the importance of ART adherence and its benefits for patient's health.

The first decade of antiretroviral therapy in Africa

The past decade has seen remarkable progress in increasing access to antiretroviral therapy in resource-limited settings. Early concerns about the cost and complexity of treatment were overcome thanks to the efforts of a global coalition of health providers, activists, academics, and people living with HIV/AIDS, who argued that every effort must be made to ensure access to essential care when millions of lives depended on it. The high cost of treatment was reduced through advocacy to promote access to generic drugs; care provision was simplified through a public health approach to treatment provision; the lack of human resources was overcome through task-shifting to support the provision of care by non-physicians; and access was expanded through the development of models of care that could work at the primary care level. The challenge for the next decade is to further increase access to treatment and support sustained care for those on treatment, while at the same time ensuring that the package of care is continuously improved such that all patients can benefit from the latest improvements in drug development, clinical science, and public health.

HIV treatment adherence, drug resistance, virologic failure: evolving concepts

Poor adherence to combined antiretroviral therapy (cART) has been shown to be a major determinant of virologic failure, emergence of drug resistant virus, disease progression, hospitalizations, mortality, and health care costs. While high adherence levels can be achieved in both resource-rich and resource-limited settings following initiation of cART, long-term adherence remains a challenge regardless of available resources. Barriers to optimal adherence may originate from individual (biological, socio-cultural, behavioral), pharmacological, and societal factors. Although patients and providers should continuously strive for maximum adherence to cART, there is accumulating evidence that each class of antiretroviral therapy has specific adherence-drug resistance relationship characteristics allowing certain regimens more flexibility than others. There is not a universally accepted measure for cART adherence, since each method has distinct advantages and disadvantages including cost, complexity, accuracy, precision, intrusiveness and bias. Development of a real-time cART adherence monitoring tool will enable the development of novel, pre-emptive adherence-improving strategies. The application of these strategies may ultimately prove to be the most cost-effective method to reduce morbidity and mortality for the individual and decrease the likelihood of HIV transmission and emergence of resistance in the community.

Retrospective study on the critical factors for retaining patients on antiretroviral therapy in KwaZulu-Natal, South Africa

OBJECTIVE

To analyze the critical factors favoring the retention of patients under antiretroviral therapy (ART) in KwaZulu-Natal (KZN), South Africa.

DESIGN AND METHODS

This retrospective study was based on the review of a representative sample of patients who began ART between March 2004 and May 2006 in 32 public sector sites and were followed up to July 1, 2007. Extended Cox proportional hazard models were used to identify the factors which significantly influenced treatment retention during the first 2 years of treatment. Kaplan-Meyer provided the probabilities of remaining on ART if these factors were present.

RESULTS

The 2835 sampled patients corresponded to about 10% of the universe of patients under ART in the 32 sites; 929 (33%) were males, and the median age of the sampled patients was 34 (interquartile range: 28-41). The analysis identified factors that significantly decreased the probability of remaining on ART. Patients' risk factors were initial CD4 <100 cells per microliter, lack of a telephone contact number, and being male. Sites' risk factors were the presence of a part time (PT) versus a full time (FT) senior professional nurse, a PT versus FT doctor, and intakes of 200 or more new patients per doctor per year. The probability of remaining on ART declined significantly for each increasing level of workload, but having a FT versus a PT doctor made a significant difference only for level of workload of 200 or more new patients per year.

CONCLUSIONS

The analysis has identified the conditions influencing retention of ART patients in KZN. This has provided a method to estimate absorption capacity of the ART delivery sites, which is of added value for a sustainable expansion of the ART coverage.

Risk of resistance to highly active antiretroviral therapy among HIV-positive injecting drug users: a meta-analysis

Although highly active antiretroviral therapy (HAART) is an effective treatment for HIV, many physicians withhold this treatment from HIV-positive injecting drug users (IDUs) because of fears of non-adherence and consequent development of antiretroviral resistance. Little is known, however, about whether the rates of resistance differ between IDUs and non-IDUs. We did a meta-analysis of studies that compared antiretroviral resistance rates in IDUs (current or previous) with those in HIV-positive patients infected by other routes and who had never injected drugs. We used a random-effects model to investigate overall resistance rates and resistance to individual drug classes. Of 181 potential studies, 27 were eligible for review. We were able to extract data from 14 studies, but two were excluded because of a very small sample size of IDUs or data being available only from a secondary analysis. Thus we included 12 studies in the meta-analysis, involving 9055 patients, of which 2054 (23%) were IDUs. The risk of development of antiretroviral resistance did not differ significantly between IDU and non-IDU (odds ratio 1.04, 95% CI 0.74-1.45, p=0.84). Rates of loss to follow-up and virological failure were similar in IDU and non-IDU samples. Existing evidence does not support the common practice of withholding antiretroviral therapy from HIV-positive IDU on the basis of an elevated risk of antiretroviral resistance. Therapeutic guidelines should consider reassessment of this issue.

Drug interactions between psychoactive substances and antiretroviral therapy in individuals infected with human immunodeficiency and hepatitis viruses

The liver disease characteristic of alcohol dependence encompasses three main related entities: steatosis, alcoholic hepatitis, and cirrhosis. Alcoholic cirrhosis is a leading cause of global morbidity and mortality. Alcohol intake among injecting drug users is a major contributor to transmission of viral infections, such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C viruses (HCV). HIV and HCV coinfected patients develop liver diseases earlier and more severely than the monoinfected individuals, including hepatocellular carcinoma. Interactions exist between the therapeutic drugs used to minimize and control the drug and alcohol dependence. Furthermore, drug-drug interactions occur between the highly active antiretroviral therapy (HAART) and alcohol, different HAART components and methadone, or each one of the therapies with the other, thus contributing to a higher toxicity level. With the evolution of effective antiretroviral therapy, survival of persons with HIV, and the syndrome it causes, acquired immunodeficiency syndrome (AIDS) has increased dramatically. Drug-drug interactions may appear between alcohol and anti-HBV or anti-HCV, therapy in the presence or absence of anti-HIV therapy. Several other medical-, social-, and drug-related factors of this population have to be considered when providing HAART. Because many coinfected patients also have problems with substance use, dealing with their drug dependence is an important first step in an attempt to improve adherence to and tolerance of antiviral therapy. It is necessary to minimize the risk of liver disease acceleration and/or reinfection with hepatitis viruses. Knowledge of potential drug interactions between methadone, antiretroviral therapy, psychoactive drugs, and antipsychotics and the role of coinfection with HBV or HCV and the drugs used in eradicating viral hepatitis permits suitable antiretroviral combinations.

[HIV management in Africa]

Africa is the continent hardest hit by the HIV pandemic with, according to the WHO for 2004, more than 25 million people infected. Although the mortality and socioeconomic consequences of HIV infection have been visible and predictable, only since 2000 has the catastrophic situation in Africa and other developing areas mobilized international political and medical attention, in view of the impressive results from antiretroviral treatments where they are accessible. The intolerable lack of access to medical care and effective treatments has engendered a fusion of energy and will - political and scientific, local and international - to make HIV treatment available in Africa. Access to treatment must be accompanied by creation of national public health programs and establishment of infrastructures and trained teams. Necessary steps including anticipation and prevention of pitfalls in the large-scale use of antiretrovirals, long-term planning, organization of supplies and distribution, ensuring the permanence of financial support, and making appropriate strategic choices. These steps are required to guarantee the future and to prevent an epidemic rebound due to drug-resistant HIV strains. The conditions of international economic and medical aid have been clarified and are now better adapted to real needs. Nonetheless large disparities still exist according to country and region. The initial results of cohorts of treated patients show results similar to those in the industrialized countries and provide encouragement about the future. Results in countries such as Uganda and Senegal show that local political involvement is primordial for long-term success. Access to antiretroviral drugs is an urgent and essential marker of comprehensive management, but the conditions of their use must be taken into account in assessing future projects if we want to change the course of HIV in Africa.

Antiretroviral therapy in resource-poor countries: illusions and realities

The prospects for antiretroviral therapy in resource-poor settings have changed recently and considerably with the availability of generic drugs, the drastic price reduction of brand-name drugs, and the simplification of treatment. However, such cost reductions, although allowing the implementation of large-scale donor programs, have yet to render treatment accessible and possible in the general population. Successfully providing HIV treatment in high-prevalence/high-caseload countries may require that we redefine the problem as a public health mass therapy program rather than a multiplication of clinical situations. The public health goal cannot simply be the reduction of morbidity and mortality for those treated but must be the reduction in morbidity and mortality for the many, that is, at a population level.

A National Survey of Clinic Sexual Histories for Sexually Transmitted Infection and HIV Screening

BACKGROUND

Optimal elements of a sexual history for sexually transmitted infection (STI) and HIV risk assessment remain undefined.

GOAL

The goal of this study was to describe sexual histories in use at STI clinics across the United States.

STUDY

This study consisted of a cross-sectional survey of facilities in cities with populations >200,000 (n = 65). Within each city, a public health STI clinic (71% of the sample) or other STI care facility (29%) was randomly selected and sexual history forms were requested. Information was obtained from 48 clinics (74% response).

RESULTS

Most forms recorded information on symptoms and prior STI (96%), condom use (88%), other contraception (85%), and numbers and gender (83%) of sex partners. Common HIV risk questions were injecting drug use (IDU; 94%), sex for drugs or money (58%), and sex with an HIV-positive or IDU partner (52%). Ascertainment of time during which risks occurred (contact periods) varied from the past 14 days to the past 12 months, with only 38% of clinics using any 1 time period. Few histories (17%) incorporated questions for men who have sex with men (MSM). Only 2 (4%) had space to record information about sexual behaviors by the HIV status of the sex partner. Condom use was infrequently assessed specifically for vaginal and anal sex (13%), and condom use problems were rarely explored (10%). Most forms documented STI/HIV counseling, although few (25%) included specific risk reduction plans.

CONCLUSIONS

Sexual histories are highly variable. Although challenging to accomplish, STI/HIV care, surveillance, and prevention may be improved by developing consensus on core questions to be used in sexual histories.

Emtricitabine: a new nucleoside analogue for once-daily antiretroviral therapy

Highly active antiretroviral therapy has resulted in a dramatic decline in morbidity and mortality among patients infected with HIV. Nevertheless, this success has to be considered in the context of the current challenges and needs in this field. Adherence, toxicity, potency and resistance are still matters of intense research, which need to improve in order to overcome the current limitations of available drugs. Regarding needs, the improvement of convenience, tolerability and pharmacokinetics run in parallel with toxicity reduction, improvement of activity (both for wild-type and resistant virus), penetration into viral reservoirs and exploitation of new targets. The Food and Drug Administration approved emtricitabine in July 2003 for use in combination with other antiretroviral agents in adults with HIV-1 infection. Approval was based on the results of two Phase III clinical trials. The first was a double-blind study comparing the safety and efficacy of emtricitabine + didanosine + efavirenz to stavudine + didanosine + efavirenz as initial treatment in individuals who had not previously received antiretroviral therapy. At 24 and 48 weeks, patients receiving emtricitabine had significantly higher rates of virological suppression and greater increases in CD4+ counts than stavudine recipients. The second study was an open-label trial in treatment-experienced patients with HIV RNA < 400 copies/ml on a lamivudine-containing regimen in combination with either stavudine or zidovudine and either a protease inhibitor or a non-nucleoside reverse transcriptase inhibitor for at least 12 weeks. Patients were randomised either to continue lamivudine (150 mg b.i.d.) or to switch to emtricitabine 200 mg o.d. while maintaining the same background medications. In this study, the proportion of patients whose viral loads remained suppressed at the < 400 and < 50 copies/ml levels were similar in the two treatment groups. Potency, tolerability, convenient dosing and a low rate of side effects are some of the main characteristics of this new drug.

Ethical issues in research on control of the HIV/AIDS epidemic: report from a workshop of the world federation of scientists, Erice, Sicily, Italy, 22-24 August 2003

In research on control of the HIV/AIDS epidemic there are many ethical issues to be considered. The problem of personal autonomy versus the interest of society to prevent the spread of the disease in various settings makes it difficult to follow the regulations of the Declaration of Helsinki in all respects. This is particularly clear in the evaluation of trials aimed at preventing mother-to-child transmission of HIV. The interest of the child does not always conform to the policy of avoiding stigmatization of the mother. Programmes for the implementation of antiretroviral therapy and vaccine trials may differ in countries with different mean incomes of the inhabitants, and are also influenced by local patterns. For this reason, the Declaration of Helsinki should be changed in such a way that it conforms with the ways in which it may be possible to combat such a disastrous epidemic as that caused by HIV.

Outcomes after two years of providing antiretroviral treatment in Khayelitsha, South Africa

BACKGROUND

A community-based antiretroviral therapy (ART) programme was established in 2001 in a South African township to explore the operational issues involved in providing ART in the public sector in resource-limited settings and demonstrate the feasibility of such a service.

METHODS

Data was analysed on a cohort of patients with symptomatic HIV disease and a CD4 lymphocyte count < 200 x 10 cells/l. The programme used standardized protocols (using generic medicines whenever possible), a team-approach to clinical care and a patient-centred approach to promote adherence.

RESULTS

Two-hundred and eighty-seven adults naive to prior ART were followed for a median duration of 13.9 months. The median CD4 lymphocyte count was 43 x 10 cells/l at initiation of treatment, and the mean log10 HIV RNA was 5.18 copies/ml. The HIV RNA level was undetectable (< 400 copies/ml) in 88.1, 89.2, 84.2, 75.0 and 69.7% of patients at 3, 6, 12, 18 and 24 months respectively. The cumulative probability of remaining alive was 86.3% at 24 months on treatment for all patients, 91.4% for those with a baseline CD4 lymphocyte count > or =50 x 10 cells/l, and 81.8% for those with a baseline CD4 lymphocyte count < 50 x 10 cells/l. The cumulative probability of changing a single antiretroviral drug by 24 months was 15.1% due to adverse events or contraindications, and 8.4% due to adverse events alone.

CONCLUSIONS

ART can be provided in resource-limited settings with good patient retention and clinical outcomes. With responsible implementation, ART is a key component of a comprehensive response to the epidemic in those communities most affected by HIV.