Antiretroviral therapy programmes in resource limited settings

In the linked study (doi:10.1136/bmj.d6792), Mermin and colleagues assess the effect of routine laboratory monitoring on clinical outcomes in patients receiving antiretroviral therapy in Uganda; in a companion study Kahn and colleagues (doi:10.1136/bmj.d6884) assess the cost and cost effectiveness of quarterly CD4 cell count measurement and monitoring of viral load in such patients.1 2

As a result of political commitment and major investment, more than 5 million people living with HIV in resource limited settings are now benefiting from antiretroviral therapy. Early efforts in the roll out of antiretroviral therapy decreased drug costs and made treatment both available and cost effective. Because of limited capacity and costs, treatment programmes rightly focused primarily on developing new delivery systems and not on laboratory monitoring.3

In contrast, in developed countries laboratory monitoring is central to patient management. For example, US guidelines recommend measuring CD4 counts and HIV-1 viral load, and performing genotyping before the start of treatment (level A evidence rating). They also recommend twice yearly measurement of CD4 counts and frequent viral load monitoring (often six times …