title: Public-health and individual approaches to antiretroviral therapy: township South Africa and Switzerland compared.
abstract: BACKGROUND
  The provision of highly active antiretroviral therapy (HAART) in resource-limited settings follows a public health approach, which is characterised by a limited number of regimens and the standardisation of clinical and laboratory monitoring. In industrialized countries doctors prescribe from the full range of available antiretroviral drugs, supported by resistance testing and frequent laboratory monitoring. We compared virologic response, changes to first-line regimens, and mortality in HIV-infected patients starting HAART in South Africa and Switzerland.
  
  
  RESULTS
  We analysed data from the Swiss HIV Cohort Study and two HAART programmes in townships of Cape Town, South Africa. We included treatment-naïve patients aged 16 y or older who had started treatment with at least three drugs since 2001, and excluded intravenous drug users. Data from a total of 2,348 patients from South Africa and 1,016 patients from the Swiss HIV Cohort Study were analysed. Median baseline CD4+ T cell counts were 80 cells/mul in South Africa and 204 cells/mul in Switzerland. In South Africa, patients started with one of four first-line regimens, which was subsequently changed in 514 patients (22%). In Switzerland, 36 first-line regimens were used initially, and these were changed in 539 patients (53%). In most patients HIV-1 RNA was suppressed to 500 copies/ml or less within one year: 96% (95% confidence interval [CI] 95%-97%) in South Africa and 96% (94%-97%) in Switzerland, and 26% (22%-29%) and 27% (24%-31%), respectively, developed viral rebound within two years. Mortality was higher in South Africa than in Switzerland during the first months of HAART: adjusted hazard ratios were 5.90 (95% CI 1.81-19.2) during months 1-3 and 1.77 (0.90-3.50) during months 4-24.
  
  
  CONCLUSIONS
  Compared to the highly individualised approach in Switzerland, programmatic HAART in South Africa resulted in similar virologic outcomes, with relatively few changes to initial regimens. Further innovation and resources are required in South Africa to both achieve more timely access to HAART and improve the prognosis of patients who start HAART with advanced disease.
authors.affiliation: Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland.
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
authors.forename: Catherine
authors.initials: C
authors.lastname: Orrell
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.forename: Martin W G
authors.initials: MW
authors.lastname: Brinkhof
authors.forename: Hansjakob
authors.initials: H
authors.lastname: Furrer
authors.forename: Gilles
authors.initials: G
authors.lastname: van Cutsem
authors.forename: Bruno
authors.initials: B
authors.lastname: Ledergerber
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
mesh_terms: D016915:AIDS Vaccines / Q000627:therapeutic use; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D015331:Cohort Studies; D024882:Drug Resistance, Viral; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology; D006801:Humans; D008297:Male; D011634:Public Health; D013019:South Africa; D013557:Switzerland
chemical_list: D016915:AIDS Vaccines; D019380:Anti-HIV Agents