Elsevier

The Lancet

Volume 368, Issue 9534, 5–11 August 2006, Pages 531-536
The Lancet

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The case for expanding access to highly active antiretroviral therapy to curb the growth of the HIV epidemic

https://doi.org/10.1016/S0140-6736(06)69162-9Get rights and content

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HAART and HIV prevention

HIV causes AIDS.32 The transmission of HIV from infected to uninfected people through exposure to an infected person's bodily fluids (mainly semen, vaginal secretions, breast milk, and blood) is established.33, 34, 35 More recently, HAART has been shown to reduce HIV-1-RNA plasma concentrations predictably to undetectable concentrations in most treated patients.36 International guidelines have uniformly recognised that sustained complete suppression of HIV-1-RNA is needed to achieve a steady

Cost effectiveness of HAART revisited

Traditionally, HAART has been deemed to be cost effective on the basis of patient-centred outcomes;55 however, this fails to consider the effect of HAART on HIV transmission. Regional incidence to prevalence ratios can be used to estimate the number of new HIV infections that have failed to materialise in 2005 in any given region. For example, to raise the index in North America to the level seen in developing countries, where access to HAART is limited, would take nearly 100 000 additional HIV

A potential HAART-driven HIV-control strategy

The patient-centred approach to HIV management is based on the use of HAART to modify the natural history of the disease with the expectation that HIV infection will be transformed into a manageable chronic condition. This approach is supported by many clinical trials and population-based studies showing that health outcomes, such as death or progression to AIDS, can be delayed as long as individuals are highly adherent to therapy and start treatment with CD4-cell counts of greater than 200 per

Conclusions

The present approach to the management of HIV/AIDS is clearly not sustainable, and the status quo no longer acceptable if we hope to control the continued growth of the HIV global pandemic. A prevention-centred approach to the use of HAART, as discussed here, would be challenging and would need careful consideration of associated emerging ethical issues. However, expanded free access to HAART on a global scale provides a potential means to curb the growth of the HIV pandemic. As such, expansion

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