Use of antiretroviral therapy in resourcelimited countries in

Use of antiretroviral therapy in resource-limited countries in 2007: up-take of 2 nd-line and pediatric treatment stagnant F. Renaud-Théry 1, B. Dongmo Nguimfack 1, M. Vitoria 1, E. Lee 2, C. Gilks 1, J. Perriëns 1 1 World Health Organization, Department of HIV and AIDS, Geneva, Switzerland, 2 Consultant, Geneva, Switzerland

Background The AIDS Medicines and Diagnostics Service (AMDS) of WHO conducts an annual survey to assess the use of ARVs in low and middle income countries. The objectives are: § to document the use of first and second line adult and pediatric ARVs while treatment programmes are scaling up § to serve as a baseline forecasting ARV demand to inform expansion of ARV production capacity of ARV manufacturers.

Approach and results A questionnaire was sent to 41 countries - 30 responded by August 2007 (73%) The 30 respondent countries covered a total number of 1, 356, 399 patients (54% of total number of patients on treatment at the time of the survey) Adults: 93% Children: 7% Total number of regimens reported: 1 st line: 39 regimens 2 nd line: 149 regimens Countries included Benin, Botswana, Brazil*, Burkina Faso, Burundi, Cambodia, Cameroon, China, Colombia, Cote d'Ivoire, Ethiopia, Guyana, India, Kenya, Lesotho, Malawi, Mali, Mexico*, Mozambique, Namibia, Nigeria, Peru, Russian Federation, Rwanda, Swaziland, United Republic of Tanzania, Thailand, Uganda, Ukraine, Viet Nam, Zambia and Zimbabwe * Brazil and Mexico are not included in this analysis because they present regimen patterns dramatically different from other countries.

Distribution of 1 st and 2 nd line regimens among adults and children:

88% of Adults on 1 st line receive regimens recommended by WHO, with a majority using d 4 T + 3 TC + NVP (51%) 1, 5% use a tenofovir-based regimen

55% of adults on 2 nd-line regimen were receiving regimens recommended by WHO, with a majotity of ABC+dd. I+LPV/r and AZT+dd. I+LPV/r tenofovir-based regimen represented 14% of second-line regimen boosted lopinavir was the large predominant protease inhibitor

91% of children on 1 st line receive regimens recommended by WHO, with a majority using d 4 T + 3 TC + NVP (42%)

Only 3% of children were on 2 nd line regimens, second-line treatment regimens in children was also with a large variety of treatment lines ZDV + 3 TC + LPV-r ABC + dd. I + LPV-r 488 24% 247 12% D 4 T + dd. I + LPV-r 171 8% D 4 T + 3 TC + LPV-r 138 7% ZDV + dd. I + LPV-r 104 5% 3 TC + dd. I + LPV-r ABC + dd. I + NFV 80 4% 52 3%

For the 21 countries that provided data on ART use in 2006 and 2007, the annual switching rate from first to second-line ART is lower than expected in 2007

Slow up-take of pediatric treatment while increasing in absolute volume, the up-take remains stable relative to adults (7% and 8% in 2007 and 2006, respectively)

Conclusion This survey documents a good compliance of first-line treatment but still a slower uptake of second-line treatment for adults and children in developing countries. Programmatic difficulties and procurement constraints need to be addressed by countries in order to reach Universal Access:

• Promotion of earlier diagnosis of treatment failure and access to second-line medicines (TDF and/or ABC and heat stable protease inhibitors) • New pediatric formulations with adapted strengths and fixed-dose combinations are being made available. Together with the increased promotion of early diagnosis and treatment in infants by WHO, this might increase the up-take of treatment in children in the near future

The results of this survey will be used to up-date the global forecasts of ARV demand for 2009 to 2012 by WHO and UNAIDS

More information on ARV forecasting is available at: http: //www. who. int/hiv/amds/forecasting/en/i ndex. html amds@who. int