Elsevier

The Lancet

Volume 360, Issue 9344, 9 November 2002, Pages 1503-1505
The Lancet

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Antiretroviral treatment in resource-poor settings: clinical research priorities

https://doi.org/10.1016/S0140-6736(02)11478-4Get rights and content

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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, 5, 6 but whether asymptomatic adults with more than 200 CD4+ cells/mm3 should also begin treatment is unclear.7, 8, 9 Guidelines vary, but the pendulum is swinging away from very early treatment towards a more cautious strategy of deferred therapy.10, 11 This shift has been fuelled by the desire to strike a balance between the efficacy of treatment and its toxic and

How should antiretroviral treatment be monitored?

Antiretroviral treatment has several characteristics suggesting that regular laboratory monitoring is important. Virological and immunological responses and failures are usually asymptomatic. Similarly, although some adverse effects of antiretroviral treatment are associated with clinical symptoms and signs, other adverse events can only be detected by laboratory assays.

Selection of antiretroviral drugs (panel 3)

Although safety, effectiveness, and acceptability should govern the choice of antiretroviral treatment, individualised regimens might not be possible in many environments. Standard low-cost regimens and algorithms to guide their use will accelerate the widespread deployment of antiretroviral treatment needed in resource-poor settings where care is provided mainly by nurses and health workers.

Selection of a first-line regimen (or regimens) is a key strategic decision. Objectives include

Adherence to antiretroviral treatment

Non-adherence is the Achilles' heel of antiretroviral treatment; it is associated with development of viral resistance,23 virological failure,24 progression of disease,25 and death.26, 27 Increasing attention is being paid to helping patients adhere to antiretroviral treatment, and treatment guidelines highlight the topic as essential to successful use of antiretrovirals. Few studies have been published about adherence to antiretroviral treatment in poorly resourced countries and the results of

Recommendations

The first 6 years of antiretroviral treatment have led to major health gains in many countries. Answers to fundamental issues on how best to use these agents, however, remain elusive. Experts in resource-rich countries continue to debate when to start antiretrovirals, which drugs to use, how to monitor toxic effects and effectiveness, and how to improve adherence. Use of antiretroviral treatment in resource-limited environments adds additional issues and complexity. Answers are desperately

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