Uptake of second-line treatment `stagnant` in developing world

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The uptake of second-line antiretroviral treatment in developing countries is `stagnant` according to a survey by the World Health Organization presented at last week’s XVII International AIDS Conference, despite substantial cuts in drug prices over the past 18 months.

However the survey, conducted in 30 countries covering 54% of patients on treatment in the developing world, only covers the period up to August 2007 and may not be a reliable guide to more recent trends.

The survey, conducted by the AIDS Medicines and Diagnostics Service (AMDS) of the World Health Organization (WHO), was designed to help forecast future demand and assess compliance with WHO treatment guidelines.


second-line treatment

The second preferred therapy for a particular condition, used after first-line treatment fails or if a person cannot tolerate first-line drugs.

first-line therapy

The regimen used when starting treatment for the first time.


Of or relating to children.


An alternative term for ‘adherence’.

boosting agent

Booster drugs are used to ‘boost’ the effects of protease inhibitors and some other antiretrovirals. Adding a small dose of a booster drug to an antiretroviral makes the liver break down the primary drug more slowly, which means that it stays in the body for longer times or at higher levels. Without the boosting agent, the prescribed dose of the primary drug would be ineffective.

The questionnaire distributed by WHO found that only 3% of adults and children taking antiretrovirals were on a second-line regimen, and only 24,620 patients (in the 21 countries which supplied data on switching) had switched treatment during the year ending August 2007 – almost the same number as in the year ending August 2006.

Among those receiving a second-line regimen 55% were receiving a lopinavir/ritonavir-based regimen. WHO recommends a boosted protease inhibitor should be used for second-line treatment, preferably with abacavir/ddI or tenofovir/3TC. There was no information about the regimens being used by the 45% of patients not receiving lopinavir/ritonavir.

Among those on first-line treatment, only 1.5% are taking a tenofovir-based regimen despite a WHO recommendation to move away from d4T-based treatment. Sixty-three per cent are taking a d4T-based first-line regimen, predominantly d4T/3TC/nevirapine (51% of all patients in respondent countries take this regimen).

The survey also found that the total uptake of paediatric antiretroviral treatment has been slow. Among children receiving treatment 42% are receiving d4T/3TC/nevirapine as first-line treatment, while 60% of those receiving second-line treatment are receiving a lopinavir/ritonavir-based regimen.

The survey was unable to determine the reasons for the low uptake of second-line treatment, but the study’s authors suggest that earlier diagnosis of first-line treatment failure may be one way to promote better uptake of second-line drugs.