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Third-line ART can improve clinical & economic outcomes in SSA
A new study has revealed that access to third-line antiretroviral treatment (ART) for HIV can be cost effective in low-resource settings, as long as there are systems in place to identify those who urgently need third-line therapy, and those who could still benefit from second-line therapy. In the study, which was published ahead of print in JAIDS, the authors examined the economic and clinical outcomes of people in Cote d’Ivoire who had failed their second-line therapy, and found that an intense treatment adherence intervention would impact positively on these two outcomes.
In sub-Saharan Africa, access to third-line line ART is limited because of cost and a lack of monitoring and evaluation to ensure effective treatment regimes. The price of second and third-line-line ART can be up to three and ten times higher than first-line treatment, respectively. As such these drugs are accessed rarely because of limited availability, and doctors being unwilling to properly diagnose ART failure if they know other treatment options are unavailable. Inadequate access to key monitoring testing such as viral load and resistance testing, mean that it is more difficult to diagnose true virological failure, and understand who is truly in need of treatment versus those who simply have poor adherence.
The researchers compared four strategies for dealing with second-line ART failure: 1) Continue second-line ART 2) Continue second-line ART with a six-month adherence programme 3) Immediately switch to third-line treatment 4) Continue second-line ART with six-month adherence programme, and if patients still fail, move to third-line treatment. The intense adherence programme consisted of monthly adherence classes and weekly contact with a social worker, via SMS or a phone call.
Of the treatment strategies, they found that a six-month intense adherence programme improved the clinical outcomes for people who failed second-line therapy. Reinforcing adherence among those who could still benefit from treatment and identifying those who needed to make the switch to third-line therapy. In countries where third-line treatment was not available, then the adherence programme would still prove to be beneficial on both outcomes. The authors also commented that making third-line treatment available would provide population-level benefits, by reducing the likelihood of onward HIV transmission.
Implementing an intense adherence reinforcement programme coupled with a minor reduction in the cost of third-line treatment meant that Cote d’Ivoire experienced both economic and clinical benefit. The authors conclude that more research into alternative treatment strategies was needed in low-resource settings to deal with people failing their second-line treatment