Antiretroviral treatment in resource-poor settings: clinical research priorities

Abstract

1and new resources have become available. 2 Although expense, feasibility, and effective delivery remain formidable barriers, public health and technical agencies have started to re-examine their assumptions and to discuss use of antiretroviral drugs in poorly resourced environments. 3 Data lending support to use of antiretroviral treatment in poorly resourced regions are few. Even in well resourced countries, clinicians still do not have evidencebased answers to simple issues such as: when to start antiretrovirals, how to monitor their therapeutic and toxic effects, and in what sequence to use them. Answers to such issues are greatly needed to speed up delivery of antiretrovirals to the populations most in need of treatment. As a working group convened by the Rockefeller Foundation, we outline an urgent research agenda that attempts to identify gaps in knowledge and to prioritise issues affecting access to treatment for the tens of millions of adults living with HIV/AIDS in poorly resourced regions. Answers to many of these questions will also benefit patients in well resourced regions. We do not address the equally important issues about use of antiretrovirals in infants and children and of prevention of mother-to-child transmission. When should antiretroviral treatment be started? Use of antiretroviral treatment is straightforward in adults with symptomatic HIV-1 disease or CD4+ counts of 200 or less, 4–6 but whether asymptomatic adults with more