Antiretroviral therapy in sub-Saharan Africa: myth or reality?

Antiretroviral therapy (ART) in the management of HIV-1 infection is associated with significant reductions in morbidity and mortality. Until recently, access to such life-saving therapy in sub-Saharan Africa, a region that bears 70% of the HIV-1 burden, has been severely limited. Thanks to the intervention of various individuals, organizations and governments and the resulting price reductions, ART is becoming a possibility for increasing numbers of AIDS patients. However, many issues remain to be resolved, some real and others myths. When is it appropriate to initiate ART and with which drugs? Are the drugs available at a reasonable price? Should monitoring follow the same approach as in the developed world or should Africa develop its own monitoring protocols? Is ART equally efficacious against non-B subtypes that predominate in Africa? How will the management of opportunistic infections (OIs) be addressed? How should adherence and the associated non-structured treatment interruptions be dealt with? Perhaps the most important question concerns the under-resourced health sector: will it be able to deliver and regulate access to ART and will this divert attention from other important healthy priorities like malaria? It is, however, not realistic to expect or demand that all requirements be fulfilled before access initiatives are implemented. Much has been learned about ART from the experiences in treatment centres like the Joint Clinical Research Centre (JCRC) in Kampala, Uganda, and reinforced during the UNAIDS Drug Access Initiative (DAI). ART in Africa is now a reality. This personal perspective attempts to review the current situation and anticipate future directions.