Survival Benefit from Non-Highly Active Antiretroviral Therapy in a Resource-Constrained Setting

Triple ARV drug therapy can greatly improve the quality and length of an HIV patient's life. However, such therapy is not always available in the developing world. In Thailand, the government only recently initiated a policy of providing triple therapy to HIV-1 infected individuals on a select basis. Before that policy went into effect, HIV-positive people were either not treated or received ARV monotherapy or dual therapy. The current study reports mortality rates and the effect of ARV drug therapy on HIV-1 patients attending a government referral hospital.

The researchers conducted a retrospective cohort study at Lampang Hospital in northern Thailand, surveying all HIV-1-infected adult patients (16 or older) who attended the clinic at Lampang's Day Care Center from October 1995 through October 1999. The scientists collected demographic, clinical, and laboratory data from hospital records, and survival status data from hospital records, letters and death certificates at the Lampang Provincial Health Office. Patient survival was analyzed for specific variables including age, sex, first CD4 count, year of registration, clinical status at first visit to the DCC, and use of antiretroviral drug(s).

The study tracked 1,081 patients, 607 of whom died during the observation period. Median age was 30, with a range from 16-69; 34.5 percent of patients were female, and 96 percent had contracted HIV through heterosexual contact. The authors found that the overall mortality rate was high. The variables clinical status, CD4 group, ARV drug group, and registered year were independently associated with death. Patients who were treated with dual therapy had a greater survival rate than those treated with monotherapy or no ARV drug. Patients who registered in 1999 died less frequently than patients who had registered earlier.

"To our knowledge," the investigators wrote, "this is the first report showing that suboptimal ARV drug regimens had a substantial survival benefit in developing countries like Thailand, where non-B subtype HIV-1 of CRF01_AE prevails: the relative reduction in mortality compared with no therapy was 35 percent by monotherapy and 57 percent by dual therapy. Our results were similar to the findings of previous studies in Western countries. The cost of dual therapy, including generic AZT, was 3.5 times less expensive than triple therapy with ritonavir at the time we closed this study. As long as the gap between the cost for suboptimal therapy and highly active antiretroviral treatment (HAART) is immense, clinicians working in resource-limited countries will continue to face the dilemma of treating a smaller number of patients with optimal therapy or a larger number with suboptimal therapy.... Many clinicians working in developing countries will continue to face the frustration of limited drug choices," the authors concluded. "A further cost reduction for other HAART therapy is also impatiently awaited."

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