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Among the most interesting and illuminating presentations at the 14th Retrovirus Conference was a plenary lecture by Matthias Egger from Berne, Switzerland [Abstract 62]. He presented summary data from an international collaborative review of antiretroviral use in 42 countries from 2003 through 2005. Analyses involved 38,050 patients from the developed world and 11,231 from four scale-up programs in sub-Saharan Africa.
Most patients in resource-limited settings start potent combination antiretroviral therapy late or very late, as do many patients in industrialized countries. Since 2000, the CD4 count at treatment initiation in developed countries has been stable at 150 to 200 cells/mm3. In sub-Saharan Africa, the CD4 count at treatment initiation was approximately 50 cells/mm3 in 2001 but has more recently risen to 100 cells/mm3. The crude mortality rate in the 4 years after treatment initiation is much higher in sub-Saharan Africa than in North America and Europe (15% vs. 5%), but this difference appears to be driven by low CD4-cell counts at treatment initiation and, subsequently, very high early mortality rates. In the 2 to 4 years after treatment initiation, outcomes are nearly equal when adjusted for age, sex, CD4-cell count, year of starting therapy, and disease stage. Of additional interest is the surprising finding that in both developed and resource-limited settings, tuberculosis is the most common opportunistic infection during the first 3 months after initiation of antiretroviral therapy.
The number of antiretroviral regimens used for initial HIV treatment varies substantially by region. In North America, more than 90% of patients start with 1 of 59 different regimens, those in Western Europe with 47, South America with 11, and Africa and Asia with 3. Regimen changes are also much more common in industrialized countries than in resource-limited settings. Despite these differences, an analysis of a subset of patients with available viral-load information from South Africa, compared with patients in the Swiss HIV Cohort, showed identical rates of virologic response (<500 copies/mL) at 12 and 24 months. Nearly all patients in both countries reached undetectable levels, and no difference was seen in rates of viral rebound.