NA-ACCORD data is out - an observational cohort study that attempted to shed more light on the age-old question that has plagued the field - when do you start HAART. Below is the link to the NEJM commentary by Sax and Baden:
NEJM -- When to Start Antiretroviral Therapy -- Ready When You Are?
The commentary is thoughtfully written, but seems to sidestep the major question in my mind - assuming we shift recommendations to early HAART initiation - what is the implication for implementing these recommendations in the developing world, where a majority of new and existing infections reside? Already countries are cash strapped to expand public health expenditures, and I understand the GFATM is concerned about it's coffers given the global recession. This study has clearly pushed for the clinical effectiveness - now comes the tricky costing exercise to see what's "cost-effective."
I know that there are actual RCTs out there - HPTN 052 / ACTG 5175 I think was supposed to answer a similar question on when to start - curious to hear what folks think.
Wednesday, April 8, 2009
Subscribe to:
Post Comments (Atom)
Posts
Thanks for posting this Sree.
ReplyDeleteNA-ACCORD was conducted in North America and not the developing world, where TB is the #1 cause of death among PLWHA. The risk of TB increases shortly after HIV infection, even before CD4+ T-cell counts drop. PLWHA are at increased risk for TB even if their CD4+ T-cell counts are >200, >350 or >500. It would be very interesting to study when to initiate HAART in a developing country settings with a high prevalence of TB to see how doing so would impact on the dual-epidemic with respect to patient and community outcomes.
You're also right to point out that developing countries are struggling to meet the demand for ARVs even when they initiate HAART only for patients with CD4s <200. Look for example at the Free State in South Africa, where delivery of ARVs had to be halted due to a lack of funds.
My friend Dr. Francois Venter, the President of the SA Clinicians Society and Head of HIV Management for the Reproductive Health Research Unit, recently wrote this editorial in The Times:
http://www.thetimes.co.za/News/Article.aspx?id=970703
For those of you interested in global health policy issues, some other blogs that may be of interest include:
-- IDSA Infectious Diseases Center for Global Health Policy & Advocacy, http://sciencespeaks.wordpress.com/
-- Claire Keeton's blog for The Times in South Africa, http://blogs.thetimes.co.za/hiv
more acronyms than a nature article!
ReplyDelete