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In recent years the case for antiretroviral therapy (ART) in those countries hardest hit by the HIV pandemic is seldom contested. Prior to the widespread availability of antiretroviral therapy in many developing countries, there were however frequent concerns expressed about the safety and feasibility of promoting widespread access to ART in countries such as those in Southern Africa. These concerns were premised on the potential “anarchy” that might be the result of weak health systems leading to widespread virological resistance,1 2 on the grounds that there were more cost-effective interventions available given the limited funding baskets at the time,3 and on the potential to do more harm than good if introducing large and complex new interventions into already weak and fragmented health systems, further increasing inequities.4 5
The first public-sector ART treatment programmes in developing countries (with the exception of Brazil) date back to 2000,6 and data are now emerging on the effectiveness of the interventions.
SURVIVAL IN TREATMENT PROGRAMMES IN DEVELOPING COUNTRIES
Three clear messages are emerging from the accumulating outcomes reporting from public-sector adult ART treatment programmes in poor countries. First, treatment is effective for those accessing ART. Hogan summarised eight programmes from resource-limited settings,7 demonstrating a range of survival outcomes at 1 and 2 years on ART, but all showing marked improvements over the anticipated natural history without ART. The comparative median survival in those eligible but not receiving ART is variously reported as 24 months, and less than a year for CD4 counts of less than 200 and less than 50 cells/μl, respectively.8
More recently the ART-LINC collaboration demonstrated cumulative mortality at 1 year of 6.4% in 2725 patients across 12 cohorts with active follow-up procedures in place.9 The city-wide treatment programme in Lusaka reported a mortality of 16.1/100 person years of ART while rapidly scaling …