National adult antiretroviral therapy guidelines in resource-limited countries: concordance with 2003 WHO guidelines?
OBJECTIVE
To investigate the existence of national adult antiretroviral therapy (ART) guidelines in 43 World Health Organization (WHO) '3 by 5' focus countries and compare their content with the 2003 WHO ART guidelines.


METHODS
Questionnaires covered initiation of ART, selection of first or second-line ART, monitoring treatment response and toxicity and dissemination of national guidelines. Weighted concordance scores were created and country scores correlated with national indicators and WHO recommendations.


RESULTS
Thirty-nine (91%) countries returned questionnaires, three of which had no national ART guidelines. Of the 36, 16 (44%) recommended to start ART based on WHO clinical staging criteria and CD4 cell count or T-lymphocyte count, 12 (33%) WHO clinical staging criteria and CD4 cell count, four (11%) only CD4 cell counts. 35 (97%) recommended a standard first-line regimen and 24 (67%) preferred stavudine + lamivudine + nevirapine; 33 (92%) recommended second-line regimens, and 24 (60%) preferred abacavir + didanosine + lopinavir/ritonavir. Thirty-one (94%) recommended CD4 cell count, possibly combined with other indicators, to monitor ART. Concordance scores were higher in countries with lower health expenditure per capita (P = 0.009) and lower GDP per capita (P < 0.03). Median concordance scores for starting ART was 100 [interquartile range (IQR), 67 to 100]; first line therapy, 70 (IQR, 60 to 80); second-line regimens, 45 (IQR, 27 to 55) and for laboratory investigations, 80 (IQR, 80 to 100).


CONCLUSIONS
Most countries had developed national ART guidelines as part of a comprehensive national HIV program. Concordance with WHO recommendations was strong on starting first-line ART regimens and routine monitoring but lower for second-line recommendations.
Beck
Eduard J
EJ
HIV Department, World Health Organization, Geneva, Switzerland.
Vitoria
Marco
M
Mandalia
Sundhiya
S
Crowley
Siobhan
S
Gilks
Charles F
CF
Souteyrand
Yves
Y
D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D023241:Antiretroviral Therapy, Highly Active / Q000592:standards*; D018791:CD4 Lymphocyte Count; D003906:Developing Countries; D016903:Drug Monitoring / Q000379:methods; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology; D006801:Humans; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D011795:Surveys and Questionnaires; D017211:Treatment Failure; D014944:World Health Organization
D019380:Anti-HIV Agents