Concerns over drug resistance should not derail efforts to provide antiretroviral therapy in resource-limited settings

The advent of potent antiretroviral (ARV) therapy has resulted in dramatic reductions in AIDS-related morbidity and mortality in the developed world. Widespread implementation of ARV therapy in the developed world has alleviated the terrible human toll and economic impact of an epidemic that strikes young people in their most productive years. This benefit must be extended to persons living with HIV worldwide. Some have questioned the wisdom of providing antiretroviral therapy in settings where the health care infrastructure is poorly developed, and where costly, sophisticated laboratory support may not be available to monitor treatment on a regular basis. They note that the prevalence of drug resistant virus has exceeded 10% among newly-infected patients in the United States, and that approximately 50% of US patients receiving care for HIV infection harbor drug-resistant virus. These figures paint an overly pessimistic view of the current state of antiretroviral therapy. Most HIV drug resistance is the consequence of suboptimal therapy provided to patients prior to the availability of modern ARV regimens. Recent studies show that first ARV regimens can achieve viral suppression in over 80% of patients using simple potent therapies available today. With many new regimens limited drug resistance is present at the time of treatment failure Drug resistance rarely is absolute, and drug resistance mutations weaken the virus. Therefore, partial virus suppression often can be maintained. For these reasons, the benefits of ARV therapy on AIDS-related morbidity and mortality have persisted to date in the developed world despite the emergence of drug resistance. Experience in Brazil, and with smaller pilot programs in rural Haiti, South Africa, and Thailand show that ARV treatment can be delivered effectively in resource-poor settings with success rates equal to those in the developed world. For example, provision of ARV treatment to more than 125,000 HIV-infected patients in Brazil has reduced AIDS-related mortality by nearly 70%. Nevertheless, the prevalence of drug-resistant virus among newly infected individuals in Brazil is only 6.6%, well below rates reported in North America and western Europe. There is no empirical evidence that viral resistance and non-adherence are a greater problem in cohorts of patients receiving potent ARV therapy in developing countries. Widespread use of suboptimal regimens due to the unregulated availability of antiretroviral drugs poses a far greater risk for dissemination of resistant viruses as compared to concerted efforts to provide appropriate ARV regimens. ARV therapy prevents AIDS and saves lives. The availability of ARV treatment also brings hope, which lessens the stigma of HIV/AIDS and strengthens efforts to prevent the spread of HIV infection. Scale-up of existing HIV treatment programs and initiation of new programs where none exist is an urgent global necessity. Financial and technical assistance to resource-poor countries must be prioritized to expand access to antiretroviral drugs and other HIV therapies. Sustainable capacity should be developed as programs are expanded, in order to strengthen systems for health care delivery. Research to improve the quality and effectiveness of ARV treatment programs in resource-limited settings and to identify optimal drug combinations to minimize ARV resistance must be supported. The tools to fight HIV/AIDS are here. Donor countries must assure that adequate resources are provided to make ARV therapy available worldwide. We must act now. This brief statement was mostly drafted by Dan Kuritzkes with input from Amilcar Tanuri, Mark Wainberg, and Joep Lange.