Antiretroviral therapy in Africa

This article explores the consequences of increasing access to HIV/AIDS antiretroviral therapy in Africa for the spread of drug resistance.

Findings and recommendations include:

• the experience of tuberculosis treatment in Africa shows that the potential short term gains from reducing individual morbidity and mortality may be far outweighed by the potential for the long term spread of drug resistance
• drug resistance arises by natural selection, mutant strains being selected when the virus replicates in sub-limiting drug concentrations
• the only way to prevent resistance is to use a drug regimen that reduces virus replication to virtually zero: a high level of intermittent therapy and poor adherence are the principal factors leading to drug resistance
• given the high levels of HIV prevalence and the lack of resources and infrastructures, HIV/AIDS antiretroviral therapy is likely to be introduced to Africa in a random and haphazard way, with inconsistent prescribing practices and poor monitoring of therapy and adherence: this risks the rapid development and transmission of drug resistance
• directly observed treatment short course (DOTS) has been suggested as a method for delivering antiretroviral therapy, although it has limited success for tuberculosis in much of Africa
• therefore, other methods for ensuring adherence need to be developed and evaluated
• ideally, the way forward for antiretroviral therapy in Africa would be to introduce treatment in controlled settings
• research programmes are needed to tackle the problems of delivery and the challenges of providing the infrastructure to ensure effective access to antiretroviral therapy

[adapted from author]