Switzerland cf. Township South Africa: HIV

This article in PLoS Medicine investigates the difference between modern multi-drug treatment with individuals monitoring of patients in a developed country (Switzerland) with similar treatments using a different, non-individualized "public health" approach in South Africa, to see if there is any difference between the two approach. The results are surprising, and encouraging.

AIDS (Acquired Immunodeficiency Syndrome) has caused the death of over 25 million people worldwide since 1981, and an additional 30 million people are currently infected with the causal agent of AIDS, the virus HIV. HIV does its ugly work by destroying cells in the immune system cells (including CD4 cells, a type of lymphocyte), leaving individuals open to other infections. At the beginning of this epidemic HIV-infected individuals typically died within 10 years of becoming infected. Starting in 1996, "highly active antiretroviral therapy" (HAART) involving several antiretroviral drugs used together as deployed.

This treatment is very expensive. This means that in richer countries, individuals receive tailored care using combinations of antiretroviral drugs taken from a menu of over 20 different choices. This treatment involves a great deal of expensive monitoring and testing as well. Because of this treatment, the prospects for HIV infected individuals has changed dramatically to the point where HIV is not necessarily the most likely ultimate cause of mortality. A person can live long enough to get run over by a truck or die of heart disease.

This situation does is not likely apply to individuals in poor countries where HAART is not available. However, a "public health approach" that is not as individualized, but still involves multiple antivirals, can be implemented in some poor countries where there is some kind of public health infrastructure. When the effective drugs are applied without the individual monitoring, is the effect the same? Also, individual monitoring seeks to track the emergence of resistant viral strains. If this is not being done, might there be a greater chance of resistant strains emerging in a poorer setting?

According to the present study, poor countries

...could not afford to provide HAART for their populations. In 2003, however, governments, international agencies, and funding bodies began to implement plans to increase HAART coverage in developing countries. By December 2006, more than a quarter of the HIV-infected people in low- and middle-income countries who urgently needed treatment were receiving HAART. However, instead of individualized treatment, HAART programs in developing countries follow a public-health approach developed by the World Health Organization. That is, drug regimens, clinical decision-making, and clinical and laboratory monitoring are all standardized. This public-health approach takes into account the realities of under-resourced health systems, but is it as effective as the individualized approach?

The present research attempts to address this question. This is done by comparing effectiveness of treatment of patients receiving HAART in South Africa to those in Switzerland

The researchers analyzed data collected since 2001 from more than 2,000 patients enrolled in HAART 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. The patients in South Africa, who had a lower starting CD4 cell count and were more likely to have advanced AIDS than the patients in Switzerland, 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 and half the patients changed to a different regimen. Despite these differences, the viral load was greatly reduced within a year in virtually all the patients and viral rebound (an increased viral load after a low measurement) 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.

These findings suggest that the public-health approach to HAART practiced in South Africa is as effective in terms of virologic outcomes as the individualized approach practiced in Switzerland. This is reassuring because it suggests that "antiretroviral anarchy" (the unregulated use of antiretroviral drugs, interruptions in drug supplies, and the lack of treatment monitoring), which is likely to lead to the emergence of viral resistance, is not happening in South Africa as some experts feared it might. Thus, these findings support the continued rollout of the public-health approach to HAART in resource-poor countries. Conversely, they also suggest that a more standardized approach to HAART could be taken in Switzerland (and in other industrialized countries) without compromising its effectiveness. Finally, the higher mortality in South Africa than in Switzerland, which partly reflects the many patients in South Africa in desperate need of HAART and their more advanced disease at the start of therapy, suggests that HIV-infected patients in South Africa and in other resource-limited countries would benefit from earlier initiation of therapy.

So far.

Keiser, O., Orrell, C., Egger, M., Wood, R., Brinkhof, M.W., Furrer, H., van Cutsem, G., Ledergerber, B., Boulle, A., Bangsberg, D. (2008). Public-Health and Individual Approaches to Antiretroviral Therapy: Township South Africa and Switzerland Compared. PLoS Medicine, 5(7), e148. DOI: 10.1371/journal.pmed.0050148