Guidelines for HIV/AIDS Treatment in Resource-Limited Areas

Author: Zhang Fujie
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Publish Date: 2005-03-01
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Four, Recommended First-Line Antiretroviral Treatment for Adults and Youth
As described in the WHO "3-5 Action Plan," it is recommended that countries promote the use of antiretroviral drugs through public health channels in resource-limited areas. This means expanding antiretroviral treatment to cover as many patients and individuals in need as possible and standardizing the treatment. It is particularly suggested that countries establish both first-line and second-line treatment regimens, allowing individuals who cannot afford or tolerate first-line or second-line regimens to be referred to specialists for personalized care. Standardized treatment regimens are a key component of the "3-5 Action Plan," helping WHO member states achieve its goals. Whether in project design or for individual patients, the following factors should be considered when selecting an ARV regimen: drug efficacy, side effects, laboratory monitoring, retention and switching of regimens, coexisting conditions (e.g., mixed infections, metabolic abnormalities), pregnancy, concurrent use of other medications (i.e., potential drug interactions), the possibility of infection with other viral strains (which may have previously been exposed to antiretroviral drugs due to prevention or treatment, leading to reduced sensitivity to one or more ARVs), and drug availability and cost (very important). High-quality fixed-dose combinations (FDCs) or coblisters should be considered for ARV medications, as they improve patient adherence, prevent the emergence of resistance, and also facilitate storage and distribution. Other considerations for developing countries include human resources, the need to distribute drugs to rural areas, high rates of tuberculosis and B and/or C hepatitis in the population, as well as the presence of multiple HIV types, subtypes, and strains. In previous versions (April 2002), WHO recommended that countries select first-line regimens consisting of two nucleosides plus one non-nucleoside or abacavir (ABC) or one protease inhibitor. Since the publication of the April 2002 guidelines, many countries have launched antiretroviral treatment programs and have determined their first-line regimens. Most treatment programs in developing countries have chosen regimens consisting of two nucleosides and one non-nucleoside reverse transcriptase inhibitor. Due to cost and hypersensitivity reactions, three-nucleoside regimens involving abacavir (ABC) combined with two other drugs are rarely used, while protease inhibitor-containing regimens have become the second choice mainly due to cost reasons (although prices have decreased). However, when determining regimens, factors such as drug load during dosing, side effects, and logistical management (sometimes requiring cold chain storage) must also be considered. When selecting non-nucleoside regimens, factors such as the efficacy and toxicity of NRTI and NNRTI components, the availability of fixed-dose combinations (see Appendix D), the need for cold chain storage, drug availability, and cost were taken into account, resulting in the four adult and youth first-line antiretroviral regimens listed in Table B. These regimens include NRTIs (d4T or ZDV), NRTIs (3TC), and NNRTIs (NVP or EFV). The choice between d4T and ZDV should be based on the country's specific circumstances, but it is recommended to have both drugs available. Initially, d4T is more tolerable than ZDV and does not require hemoglobin monitoring. However, in developed countries, d4T has been associated with lipodystrophy and other metabolic abnormalities, such as elevated lactate (especially when combined with ddI), which can also cause peripheral neuropathy and pancreatitis. ZDV has also been linked to metabolic complications of treatment, but to a lesser extent than d4T. Common drug-related side effects are often seen with ZDV (headache, vomiting) and can also cause severe anemia and neutropenia, requiring at least hemoglobin monitoring before and during treatment. If ZDV is not tolerated, d4T can be used as a substitute, and vice versa (except in cases of suspected lactic acidosis, where neither drug should be used). However, for most patients in severely resource-limited settings who need rapid treatment, d4T can be chosen as the nucleoside reverse transcriptase inhibitor due to its fewer laboratory monitoring requirements.