HIV-infected patients starting highly active antiretroviral therapy (HAART) in developing countries have increased mortality rates in the first months on therapy compared with those in developed countries, according to a paper in this week's issue of The Lancet. The authors state that early diagnosis and assessment of treatment eligibility, coupled with free provision of HAART, might reduce this excess mortality.

HAART has substantially improved the prognosis of HIV-infected patients who have access to these drugs. HAART is being scaled up in developing countries but several factors could limit the effectiveness of the therapy in resource-poor settings.

In this study the researchers compared the ART-LINC Collaboration--a network of 18 HAART programmes in Africa, Asia, and South America--with a similar network of 12 HAART programmes in Europe and North America. They found that mortality was higher in low-income settings than in high-income settings. Patients in low-income countries had lower CD4 cell counts (indicating an increased risk of infection) and more advanced clinical disease when they started treatment. However, the authors state that this only partly explains the higher mortality. They believe accompanying illnesses (comorbidities) such as tuberculosis that are present in many low-income settings may have increased mortality. They also found that the provision of treatment free of charge in low-income settings was strongly associated with lower mortality.

Author Dr Matthias Egger (University of Berne, Switzerland) concludes: "Antiretroviral therapy is feasible and effective in low income settings, but, compared with industrialized countries, mortality is high in the first months. Eligibility for antiretroviral treatment and the need for treatment of tuberculosis should be determined earlier, and HAART should be started before serious comorbidities develop."

In an accompanying Editorial, The Lancet comments: "The start of th
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Contact: Joe Santangelo
j.santangelo@elsevier.com
212-633-3810
Lancet
9-Mar-2006

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