Anti Retroviral Therapy: Clinical Outcomes and Program Development

The evolution of anti-retroviral therapy in resource limited settings

This session showcased the battle of many clinicians in the region to optimise therapy for their patients. Dr Panita Pathipvanich from Lampang Hospital in northern Thailand documented in a retrospective review the improved survival using dual ARV therapy compared to either mono-therapy or no therapy. Triple therapy remains out of reach for most PLWHAs with only seven percent receiving this combination. This paper and the ensuing discussion continued the debate about whether to give dual therapy to many people or triple therapy to a minority.

Dr Dattatray Saple from Mumbai,India took the issue of ARV resistance further. He analysed 200 patients from various socio-economic groups who were failing ARV therapy. Sub-optimal initial therapy was almost universal with only 10 percent counselled prior to therapy, 61 percent not treated for underlying opportunistic infections, mistakes made in combinations and dosages and therapy frequently interrupted for a wide range of reasons. 64 percent of the group failed to improve with the limited salvage therapy that could be offered. Dr Saple called for steps to increase training and regulation of ARV prescription to be "taken on a war footing". Lay Myint from Myanmar, currently working at the National Institute of Infectious Diseases in Japan presented an approach to the monitoring of ARV resistance in resource limited setting. He described a technique of using a "mutagenically separated" PCR to detect the common AZT resistance mutations (M41L and K70R).This has the potential to be significantly cheaper than the current assays. A team from the United States proposed another cost-effective approach to ARV therapy. They are evaluating the use of total lymphocyte count (TLC) to monitor immune suppression. As in many previous studies they found a 70 - 80 percent correlation with CD4 count. Many Indian clinicians pointed out in discussion that the reliability of TLC also needs to be assessed as this is often done by hand and operator dependent. Other reports presented were a description of a series of patients with Immune Restoration Disease from Dr Sanjay Pujari, India and a presentation on the increasing incidence of serious hepatic disease in a cohort of people in Japan with HIV and haemophilia by Dr Shinobu Tatsunami.