Therapies: confronting the limits of success

Limitations of antiretroviral therapies must be included in the scaling-up debate

This article reports on the prevailing mood about the successes and limitations of antiretroviral drugs. The author charts the development of different drug strategies since 1996 (when a cocktail of drugs was first shown to control HIV), and canvasses expert opinion on their successes and limitations.

The author argues that while the 16 different anti-HIV drugs now approved by the U.S. Food and Drug Administration have led to dramatic declines in AIDS-related disease and mortality, over the last 6 years the limitations of ARVs have become more apparent.

While in the past many clinicians advocated a 'hit early, hit hard' treatment philosophy, now that so many serious long-term side effects have surfaced with these drugs, many are now delaying treatment until infected people living with HIV/AIDS are in imminent danger of symptomatic disease.

Side-effects, combined with the increasingly recognised 'pill fatigue', have led many to abandon treatment plans and thereby increasing the danger of drug resistance to existing drugs. As a consequence, transmission of resistant strains is now on the rise. Other limitations include:

when the side-effects of HAART become severe, people undergoing treatment often switch to a different cocktail of drugs. However, each time the cocktail is changed the treatment shows to be effective for less time
is it still unclear at what point treatment should be started to be most effective
it is unrealistic to expect people to adhere to strict and complex drug taking regimen and therefore the controlled tests of the drugs to not reflect real life

The author concludes that there is little doubt that ARVs have made a significant impact on the lives of people living with HIV/AIDS. However, there are many issues concerning their effectiveness and impact that are still unresolved. Therefore the debate concerning ARVs in developing countries should not only focus on accessibility and cost but also on the limitations of relying on ARVs alone to treat and care of people living with HIV/AIDS.

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Therapies: confronting the limits of success