Rapid progress in developing antiretroviral therapy (ART) led in 1996 to the introduction of highly active antiretroviral therapy (HAART). This revolutionized the treatment of HIV infection. HAART is a combination of at least three antiretroviral (ARV) drugs.As with anti-TB treatment, a combination of ARV drugs provides efficacy and decreases risk of drug resistance. HAART is the global standard of care in the treatment of HIV infection.Although not a cure for HIV infection, HAART usually results in near-complete suppression of HIV replication. Treatment has to be lifelong.
ART results in dramatic reductions in morbidity and mortality in HIV-infected people. There are several requirements for successful use of ART. These include considerable efforts to maintain adherence to lifelong treatment and to monitor response to treatment, drug toxicities and drug interactions.
Although the benefits of ART are considerable, administration is not easy. Many HIV-infected persons cannot tolerate the toxic effects of the drugs. Adherence is difficult because of often large numbers of pills and complicated treatment regimens. Poor adherence to treatment leads to the emergence of drug-resistant viral strains, which are very difficult to treat. Careful monitoring of patients is necessary to evaluate response to treatment.
HAART is the global standard of care. However, access is limited to very few HIV-infected people where the burden of HIV is greatest (in sub-Saharan Africa and Asia). WHO estimated that in 2002 there were 6 million people in developing countries in need of ART. Of these, only 230000 had access to ART (and half of those were in one country, Brazil). There are increasing international efforts to improve access to ART in resource-limited settings. Drug costs (one of the major barriers to access in poor countries) are rapidly declining. Modification of drug patent laws is under discussion to allow resource-poor countries to import cheap generic versions of the drugs. Pilot schemes are under development to ensure proper and safe drug administration and distribution at district level. The WHO Model List of Essential Drugs includes eight ARV drugs. WHO has published guidelines for a public health approach to scaling up ART in resource-limited settings. These developments will facilitate the achievement of the target to have 3 million people in developing countries on ART by 2005.
ART will become increasingly available in resource-poor countries. Clinicians treating TB patients need to be familiar with the principles and practice of ART. This chapter therefore provides a brief guide to ART, including the specific treatment of HIV infection in TB/HIV patients.You should consult the suggestions for further reading for more comprehensive guidance on ART. In this rapidly evolving field, you should also consult national and international authorities for regularly updated guidance. The WHO website is a useful source of up-to-date guidance (http://www.who.int/HIV).
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