HIV This Week

Beck EJ, Vitoria M, et al. National adult antiretroviral therapy guidelines in resource-limited countries: concordance with 2003 WHO guidelines? AIDS 2006;20:1497-1502

Beck and colleagues investigated the existence of national adult ART guidelines in 43 WHO 3 by 5 focus countries and compared their content with the 2003 WHO ART guidelines. Questionnaires covered initiation of ART, selection of first or second-line ART, monitoring treatment response and toxicity and dissemination of national guidelines. Weighted concordance scores were created and country scores correlated with national indicators and WHO recommendations. Thirty-nine (91%) countries returned questionnaires, three of which had no national ART guidelines. Of the remaining 36, 16 (44%) recommended to start ART based on WHO clinical staging criteria and CD4 cell count or T-lymphocyte count, 12 (33%) WHO clinical staging criteria and CD4 cell count, and 4(11%) only CD4 cell counts. 35 (97%) recommended a standard first-line regimen and 24 (67%) preferred stavudine + lamivudine + nevirapine; 33 (92%) recommended second-line regimens, and 24 (60%) preferred abacavir + didanosine + lopinavir/ritonavir. Thirty-one (94%) recommended CD4 cell count, possibly combined with other indicators, to monitor ART. Concordance scores were higher in countries with lower health expenditure per capita (P=0.009) and lower GDP per capita (P<0.03). Median concordance scores were: starting ART, 100 [interquartile range (IQR) 67 to 100]; first line therapy, 70 (IQR 60 to 80); second-line regimens, 45 (IQR 27 to 55) and laboratory investigations, 80 (IQR 80 to 100). The authors conclude that most countries had developed national ART guidelines as part of a comprehensive national HIV program. Concordance with WHO recommendations was strong on starting first-line ART regimens and routine monitoring but lower for second-line recommendations.