Popp D, Fisher JD. First, do no harm: a call for emphasizing adherence and HIV prevention interventions in active antiretroviral therapy programs in the developing world

Department of Psychology, University of Connecticut, Storrs, Connecticut, United States
AIDS (Impact Factor: 5.55). 04/2002; 16(4):676-8. DOI: 10.1097/00002030-200203080-00025
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Available from: Jeffrey D. Fisher, May 30, 2014
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    • "Inevitably, the long-term challenges of providing ART will become increasingly evident, including late drug toxicities, treatment failure and emergence of drug resistance [2-4]. Indeed, some have argued that scaling up ART in Africa could create widespread drug resistance [5,6]. Early reports, however, have documented good adherence to therapy [7] and short-term virological efficacy comparable to industrialized countries [8]. "
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    ABSTRACT: Virological response to antiretroviral treatment (ART) in rural Africa is poorly described. We examined virological efficacy and emergence of drug resistance in adults receiving first-line ART for up to 4 years in rural Tanzania. Haydom Lutheran Hospital has provided ART to HIV-infected patients since October 2003. A combination of stavudine or zidovudine with lamivudine and either nevirapine or efavirenz is the standard first-line regimen. Nested in a longitudinal cohort study of patients consecutively starting ART, we carried out a cross-sectional virological efficacy survey between November 2007 and June 2008. HIV viral load was measured in all adults who had completed at least 6 months first-line ART, and genotypic resistance was determined in patients with viral load >1000 copies/mL. Virological response was measured in 212 patients, of whom 158 (74.5%) were women, and median age was 35 years (interquartile range [IQR] 29-43). Median follow-up time was 22.3 months (IQR 14.0-29.9). Virological suppression, defined as <400 copies/mL, was observed in 187 patients (88.2%). Overall, prevalence of > or =1 clinically significant resistance mutation was 3.9, 8.4, 16.7 and 12.5% in patients receiving ART for 1, 2, 3 and 4 years, respectively. Among those successfully genotyped, the most frequent mutations were M184I/V (64%), conferring resistance to lamivudine, and K103N (27%), Y181C (27%) and G190A (27%), conferring resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs), whereas 23% had thymidine analogue mutations (TAMs), associated with cross-resistance to all nucleoside reverse transcriptase inhibitors (NRTIs). Dual-class resistance, i.e. resistance to both NRTIs and NNRTIs, was found in 64%. Virological suppression rates were good up to 4 years after initiating ART in a rural Tanzanian hospital. However, drug resistance increased with time, and dual-class resistance was common, raising concerns about exhaustion of future antiretroviral drug options. This study might provide a useful forecast of drug resistance and demand for second-line antiretroviral drugs in rural Africa in the coming years.
    Full-text · Article · Feb 2009 · BMC Infectious Diseases
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    • "Both scenarios could lead to noncompliance with ART over time, or a false sense of safety when engaging in unprotected sex. Limited research on voluntary HIV-antibody testing and antiretroviral therapy in poor African populations suggests that such services can be feasibile, efficacious and acceptable (Diomandé et al., 2003; Desclaux et al., 2003) although adherence interventions that focus on information, motivation and behavioural skills may be essential to making them effective (Popp and Fisher, 2002). The terrible conditions faced by people with AIDS in rural Mwanza are similar to those elsewhere in SSA, emphasising the critical need to undertake such efforts on a larger scale. "
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    ABSTRACT: Most people living with AIDS in sub-Saharan Africa have had neither a biomedical diagnosis nor antiretroviral medication, leading to the question of how individuals understand and treat AIDS. This study examined general illness, sexually-transmitted infection (STI) and AIDS treatment-seeking behaviour in rural Mwanza, Tanzania. From 1999-2002, participant observation was carried out in nine villages for a total of 158 person-weeks. Treatments were pluralistic and opportunistic, usually beginning with home remedies (western or traditional), followed by visits to traditional healers (THs) and/or health facilities (HFs). THs were sometimes preferred over HFs because of familiarity, trust, accessibility, expense, payment plans, and the perceived cause, nature and severity of the illness, e.g. only THs were believed to successfully treat bewitchment. Some people, particularly young girls, delayed or avoided seeking treatment for STIs for fear of stigma. Most STIs were attributed to natural causes, but AIDS was sometimes attributed to witchcraft. Locally available biomedical care of people with AIDS-like symptoms consisted of basic treatment of opportunistic infections. Most such individuals repeatedly visited THs and HFs, but many stopped attending HFs because they came to believe they could not be cured there. Some THs claimed to cure witchcraft-induced, AIDS-like illnesses. There is an urgent need for improved biomedical services, and TH interventions could be important in future HIV/AIDS education and care.
    Full-text · Article · Aug 2006 · AIDS Care
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