Abstract
BackgroundThe range of combination antiretroviral therapy (cART) regimens available in many middle-income countries differs from those suggested in international HIV treatment guidelines. We compared first-line cART regimens, timing of initiation and treatment outcomes in a middle income setting (HIV Centre, Belgrade, Serbia - HCB) with a high-income country (Royal Free London Hospital, UK - RFH).MethodsAll antiretroviral-naïve HIV-positive individuals from HCB and RFH starting cART between 2003 and 2012 were included. 12-month viral load and CD4 count responses were compared, considering the first available measurement 12-24 months post-cART. The percentage that had made an antiretroviral switch for any reason, or for toxicity and the percentage that had died by 36 months (the latest time at which sufficient numbers remained under follow-up) were investigated using standard survival methods.Results361/597 (61 %) of individuals initiating cART at HCB had a prior AIDS diagnosis, compared to 337/1763 (19 %) at RFH. Median pre-ART CD4 counts were 177 and 238 cells/mm3 respectively (p < 0.0001). The most frequently prescribed antiretrovirals were zidovudine with lamivudine (149; 25 %) and efavirenz [329, 55 %] at HCB and emtricitabine with tenofovir (899; 51 %) and efavirenz [681, 39 %] at RFH. At HCB, a median of 2 CD4 count measurements in the first year of cART were taken, compared to 5 at RFH (p < 0.0001). Median (IQR) CD4 cell increase after 12 months was +211 (+86, +359) and +212 (+105, +318) respectively. 287 (48 %) individuals from HCB and 1452 (82 %) from RFH had an available viral load measurement, of which 271 (94 %) and 1280 (88 %) were <400 copies/mL (p < 0.0001). After 36 months, comparable percentages had made at least one antiretroviral switch (77 % HCB vs. 78 % RFH; p = 0.23). However, switches for toxicity/patient choice were more common at RFH. After 12 and 36 months of cART 3 % and 8 % of individuals died at HCB, versus 2 % and 4 % at RFH (p < 0.0001).ConclusionIn middle-income countries, cART is usually started at an advanced stage of HIV disease, resulting in higher mortality rates than in high income countries, supporting improved testing campaigns for early detection of HIV infection and early introduction of newer cART regimens.
Highlights
The range of combination antiretroviral therapy regimens available in many middle-income countries differs from those suggested in international human immunodeficiency virus (HIV) treatment guidelines
In contrast to high income settings, the choice of combination antiretroviral therapy (cART) regimen predominantly depends on which antiretroviral drugs are available, regardless of those recommended in treatment guidelines [4, 5]
The Strategic Timing of Antiretroviral Treatment (START) study showed that immediate initiation of cART with a CD4+ T-cell count >500 cells/mm3 led to lower rates of serious acquired immune deficiency syndrome (AIDS)-related and non-AIDSrelated illnesses and death compared to deferring cART until the CD4 count reached 350 cells/mm3 [5]
Summary
The range of combination antiretroviral therapy (cART) regimens available in many middle-income countries differs from those suggested in international HIV treatment guidelines. We compared first-line cART regimens, timing of initiation and treatment outcomes in a middle income setting (HIV Centre, Belgrade, Serbia - HCB) with a high-income country (Royal Free London Hospital, UK - RFH). Since the introduction of combination antiretroviral treatment (cART), morbidity and mortality in those living with human immunodeficiency virus (HIV) has dramatically decreased [1, 2]. In contrast to high income settings, the choice of cART regimen predominantly depends on which antiretroviral drugs are available, regardless of those recommended in treatment guidelines [4, 5]. In reality HIV-testing rates in high income countries are higher compared to low, low-middle and middle income settings. Higher numbers of individuals with HIV are diagnosed late and start cART with more advanced disease in these settings, with resulting higher mortality rates [3,4,5]
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