Rational use of antiretroviral therapy in low-income and middle-income countries: optimizing regimen sequencing and switching

Julian H Elliot, Lut Lynen, Alexandra Calmy, Andrea De Luca, Robert W Shafer, Maria Zolfo, Bonaventura Clotet, Sarah Huffam, Charles Boucher, David A Cooper, Jonathan M. Shapiro

Risultato della ricerca: Contributo in rivistaArticolo in rivista

25 Citazioni (Scopus)


During the 4 years to the end of 2007, the number of people in low-income and middle-income countries (LMICs) receiving antiretroviral therapy (ART) increased from 400 000 to 3 million [1,2]. Although early mortality [3] and retention in care [4] remain significant challenges, the majority of reports from LMICs have shown encouraging immunological, virological and survival outcomes [5 12]. Reported rates of switching to second-line ART regimens have been lower than expected [13 15], in part due to actual rates of treatment success, but mainly because of limited access to both virological monitoring [16] and second-line drugs [14]. Clinicians have also been reluctant to switch therapy [15] due to regimen cost, complexity, inconvenience and lack of subsequent treatment options. As cohorts mature and expand and access to virological monitoring and second-line regimens increase, however, rates of diagnosed treatment failure and switch to second-line regimens will increase [17]. As the cost of second-line regimens are currently three to 20 times more expensive than that of first-line regimens [18], these increases will challenge the cost-effectiveness [19,20] and sustainability [21] of HIV-treatment programmes.An effective response to the challenges of HIV treatment failure in LMICs must include reductions in the cost of second-line agents [22], but changes to commercial regulations, particularly in India, suggest the scale of price reductions seen with first-line agents are unlikely to occur with second-line agents. Strategies to maximize the effectiveness of first-line and second-line regimens and optimize the timing of regimen switching are required to fully utilize the survival benefit of available treatment options, maintain programme cost-effectiveness and enable achievement of universal access to HIV treatment. A comprehensive strategy must be evidence based and focused on the rational long-term use of ART at a population level. The objective of this review is to support the development of these strategies by providing an overview of available evidence with an emphasis on regimen sequencing and switching.
Lingua originaleEnglish
pagine (da-a)2053-2067
Numero di pagine15
Stato di pubblicazionePubblicato - 2008


  • antiretroviral therapy
  • hiv


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