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The Body Covers: The XIII International AIDS Conference
Debate: Affordable Drugs, Antiretroviral Therapy

July 11, 2000

  • Debate: Until there are more affordable drugs, antiretroviral therapy less than HAART is acceptable in developing countries (TuOr52-53)
    For: P. Phanuphak (Thailand); Against: J. Montaner (Canada)

This conference highlighted ongoing problems with inequities of access to antiviral medications. There are many countries with high rates of HIV infection but very low rates of accessing antivirals. However, research in the developed countries has led to the conclusion that while one antiviral might have some benefit for a short period of time, and two nucleosides also might have some benefits, three antivirals often show a more durable response. However, three antivirals have a cost impact that puts this standard of treatment beyond the reach of many countries, where even treating with one or two antivirals might be economically difficult.

In Thailand this is a reality and Dr. Phanuphak reviewed this difficult problem for those in his country. He discussed the data generated over the first decade of HIV treatment research that showed how using one or two nucleoside antivirals did improve health, at least for some period. He included information from studies done in the US (ACTG 175) and Europe (CAESAR and Delta). All three of these studies defined the benefit of two nucleosides, and even the potential for just ddI to be of benefit in prolonging the health of those who were positive.

Studies recently done in Thailand confirmed that a fair percentage of people treated with two nucleosides have had reasonable viral suppression. Finally, Dr. Phanuphak reviewed data that supported the potential second regimens after these regimens, noting a reasonable success rate in many cases. He acknowledged that the benefit of one or two drug approaches will be much shorter than what is expected with triple-drug therapy, but felt that for some, a short-term benefit was all that could be afforded. He ended with the conundrum that in Thailand -- where there are inadequate resources -- and where they are responsible for treating many people with infection, they face the following question: should they treat 5,000 people with triple-drug therapy, or 10,000 with two drug therapy?

As triple-drug treatment is currently beyond the economic means of many countries, such dilemmas are a common challenge -- with too many countries facing even more stark dilemmas than Thailand.

Dr. Montaner of Canada proposed a different strategy. Reviewing data from the experience of their group in Vancouver, he presented the findings of the outcome of treatment in the past few years. Specifically, they explored the rates of survival, noting both the impact of viral load and CD4 when treatment was started. Somewhat surprisingly, the viral load at the time treatment was started did not appear to have a significant impact in the future rates of survival, whereas the CD4 count did. As would be expected, the lower the CD4 count the higher the risk of dying from HIV-related illness. They noted, however, that over a period of a few years, those whose CD4 counts were below 200 were at considerably higher risk of dying as compared to those with above 200 cells. When looking at CD4 counts below 200, there clearly is more risk the lower the count gets, with those below 50 at even higher risk. Therefore, Dr. Montaner suggested an alternative approach when resources are scarce. His approach would be to treat with triple-drug combinations in those with lower CD4 counts (below 200) who are at the highest risk of complications from HIV, rather than give two drugs to those with a CD4 count over 200. However, one question from the audience reminded him that even if with a delay to below 200 cells, there are still many countries with more need for treatment than can be afforded, and thus it is still necessary to face the dilemma described by Dr. Phanuphak.

See Also
More Viewpoints on HIV Policy and Funding in the Developing World

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