Use of antiretroviral therapy in resource-limited countries in 2007: up-take of 2nd-line and pediatric treatment stagnant
F. Renaud-Théry1, B. Dongmo Nguimfack1, M. Vitoria1, E. Lee2, C. Gilks1,J. Perriëns1
1World Health Organization, Department of HIV and AIDS, Geneva, Switzerland, 2Consultant, Geneva, Switzerland
Background
The AIDS Medicines and Diagnostics Service (AMDS) of WHO conducts an annual survey to assess the use of ARVs in low and middle income countries. The objectives are: to document the use of first and second line adult and pediatric ARVs while treatment programmes are scaling up to serve as a baseline for forecasting ARV demand to inform expansion of ARV production capacity of ARV manufacturers.
Approach and results
A questionnaire was sent to 41 countries - 30 responded by August
2007 (73%) The 30 respondent countries covered a total number of 1,356,399 patients (54% of total number of patients on treatment at the time of the survey) Adults: 93% Children: 7% Total number of regimens reported: 1st line: 39 regimens 2nd line: 149 regimens
Countries included Benin, Botswana, Brazil*, Burkina Faso, Burundi, Cambodia, Cameroon, China, Colombia, Cote d'Ivoire, Ethiopia, Guyana, India, Kenya, Lesotho, Malawi, Mali, Mexico*, Mozambique, Namibia, Nigeria, Peru, Russian Federation, Rwanda, Swaziland, United Republic of Tanzania, Thailand, Uganda, Ukraine, Viet Nam, Zambia and Zimbabwe *
Brazil and Mexico are not included in this analysis because they present regimen patterns dramatically different from other countries.
Distribution of 1st and 2nd line regimens among adults and children:
1st Line 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 97% 2nd Line 97%
3% Adult
3% Children
88% of Adults on 1st line receive regimens recommended by WHO, with a majority using d4T + 3TC + NVP (51%) 1,5% use a tenofovir-based regimen
100% 88% 80%
60%
51%
40%
20%
14%
12%
9% 1,5%
0%
D4T/3TC/NVP ZDV/3TC/NVP D4T/3TC/EFV ZDV/3TC/EFV TDF based regimens total
55% of adults on 2nd-line regimen were receiving regimens recommended by WHO, with a majotity of ABC+ddI+LPV/r and AZT+ddI+LPV/r tenofovir-based regimen represented 14% of second-line regimen boosted lopinavir was the large predominant protease inhibitor
60%
50%
55%
40%
30%
20%
15%
14% 7% 7% 4%
10%
3%
2% ddI 3TC LPV-r
1% ABC TDF LPV-r
1% D4T ddI LPV-r total
0%
ABC ddI ZDV ddI LPV-r LPV-r
ZDV 3TC LPV-r
TDF 3TC LPV-r
TDF FTC LPV-r
D4T 3TC LPV-r
91% of children on 1st line receive regimens recommended by WHO, with a majority using d4T + 3TC + NVP (42%)
100%
91%
80%
60%
42%
40%
29%
20%
11%
9%
0%
D4T + 3TC + NVP
ZDV + 3TC + NVP
ZDV + 3TC + EFV
D4T + 3TC + EFV
total
Only 3% of children were on 2nd line regimens, second-line treatment regimens in children was also with a large variety of treatment lines ZDV + 3TC + LPV-r ABC + ddI + LPV-r D4T + ddI + LPV-r D4T + 3TC + LPV-r 488 247 171 24% 12% 8%
138
104 80 52
7%
5% 4% 3%
ZDV + ddI + LPV-r
3TC + ddI + LPV-r ABC + ddI + NFV
For the 21 countries that provided data on ART use in 2006 and 2007, the annual switching rate from first to second-line ART is lower than expected in 2007
1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 First-line ART Second-line ART
2006 2007
938,246 692,430
30,340
24,620
Slow up-take of pediatric treatment
while increasing in absolute volume, the up-take remains stable relative to adults (7% and 8% in 2007 and 2006, respectively)
Conclusion
This survey documents a good compliance of first-line treatment but still a slower uptake of second-line treatment for adults and children in developing countries. Programmatic difficulties and procurement constraints need to be addressed by countries in order to reach Universal Access:
• Promotion of earlier diagnosis of treatment failure and access to second-line medicines (TDF and/or ABC and heat stable protease inhibitors) • New pediatric formulations with adapted strengths and fixed-dose combinations are being made available. Together with the increased promotion of early diagnosis and treatment in infants by WHO, this might increase the up-take of treatment in children in the near future
The results of this survey will be used to up-date the global forecasts of ARV demand for 2009 to 2012 by WHO and UNAIDS
More information on ARV forecasting is available at: http://www.who.int/hiv/amds/forecasting/en/i ndex.html amds@who.int