The Extraordinary Hope of Antiretroviral Therapy in South Africa
The article “Therapeutic response of HIV-1 subtype C in African patients coinfected with either Mycobacterium tuberculosis or human herpesvirus-8” in this issue of the Journal of Infectious Diseases demonstrates that outstanding virologic and immunologic responses to triple combination antiretroviral therapy (ART) occur in South African patients. These observations provide important insight into the feasibility of treating HIV-infected persons in resource-limited settings.
HIV and AIDS treatment in North America and Europe was revolutionized by the use of triple combination ART, which resulted in dramatic decreases in morbidity and mortality. As the potency, adverse effects, and ease of ART administration continue to improve, HIV is becoming more and more manageable within the developed world. The hallmark of triple combination ART has been profound suppression of viral load to undetectable levels (<400 copies/mL) with increases in CD4+ cell counts. Moreover, ART has uniformly translated to improved health for HIV-infected persons by decreasing the risk of AIDS-related complications and death, as well as by decreasing the overall cost of medical care. Unfortunately, the benefits of ART have been slow to arrive in the developing world, particularly in sub-Saharan Africa, which bears a disproportionate burden of the HIV/AIDS epidemic. As ART has percolated slowly into the developing world, 2 myths have been propagated. The first myth is that the benefits of ART observed in developed areas of the world cannot be replicated in resource-poor settings. This myth gave rise to many arguments that have been made to discourage the introduction of this extraordinary, life-saving therapy in the areas of the world that need it the most. The past 12 months have provided an array of studies, including the study by Cassol et al. in this issue of the Journal, that have shattered this myth. The Cassol et al. study and studies conducted in Cameroon, southern India, and southern Africa have demonstrated dramatically the positive impact of triple combination ART in the developing world. HIV-1 subtype C appears to respond no differently to ART than does subtype B. Adherence in resource-poor settings (when access is guaranteed) is excellent —often better than in North American or European patients. These studies have also shown that the active ingredients in the most commonly used generic ARTs are comparable to “brand name” ART medications.
The second myth is that patients in the developing world will be too ill with farprogressed opportunistic infections (OIs) to benefit from ART. The study by Cassol et al. in this issue of the Journal addresses the use of ART for the treatment of HIV in persons who have clinical manifestations of coinfection with Mycobacterium tuberculosis or human herpesvirus-8 (HHV-8).