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Half of patients in sub-Saharan Africa who take antiretroviral drugs die or discontinue treatment within two years of starting it, new research shows.
For many patients treatment centres are too far away or the cost of drugs too high. Other patients start antiretroviral treatment too late or are deterred by the side effects, say US and South African researchers in a review in PLoS Medicine (2007;4:e298).
Their review of the literature indicates that around 40% of patients were lost to treatment after two years. They estimate, however, that the true figure is likely to be around 50%.
The review's lead author, Sydney Rosen, of the Boston University School of Public Health, said, “For those who have struggled to launch and expand treatment programmes in resource constrained settings, reaching a 60% patient retention after two years of treatment in just a few years' time is an extraordinary achievement.
“At the same time, losing up to half of those who initiate therapy within two years is cause for concern.”
The review notes that many people who start antiretroviral treatment in sub-Saharan African already have very advanced disease and that stopping treatment in such circumstances could quickly prove fatal. Dropout rates vary hugely across treatment centres, however, and the authors say that it is vital for the centres with the worst retention rates to learn from the best.
A leading HIV specialist in South Africa, Glenda Gray, from the University of Witwatersrand, said that having 40% or more of patients drop out “was simply not good enough.”
Professor Gray said, “It's not enough just supplying the drugs. People need to be reminded that they have to keep on taking them. I suspect that many people start to feel better once they've taken the drugs for a while, and once this happens they stop taking them. We need to get better at supporting and educating patients.”
Meanwhile Unicef's South Africa representative, Macharia Kamau, has warned that the country's rates of infection and mortality from HIV were outpacing treatment.
Mr Kamau said that there could be five million orphans in South Africa by 2015 if present trends continued. Unicef says that greater political leadership is needed to challenge the stigma that still surrounds the disease in South Africa.
The PLoS Medicine article says that some people may abandon treatment programmes for fear that their HIV status will be disclosed, putting them at risk of social exclusion or even physical danger.
The global fight against AIDS had already suffered a major setback last month with the news that Merck had halted trials of its HIV vaccine—generally considered one of the most promising in development.
The adenovirus vaccine had conspicuously failed to prevent infection in a study of 3000 high risk volunteers around the world (BMJ 2007;335:636, 29 Sep doi: 10.1136/bmj.39349.473785.68). A follow-up trial to be conducted in South Africa by Professor Gray was also cancelled. She said, “That was a big blow. It's going to be hard to move forward after that.”
Last year 2.9 million people died from AIDS, 2.1 million of them in sub-Saharan Africa. Over 20 million people in the region are currently thought to be infected with the virus.