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• W2080702947 abstract "To the Editors: Recently released results of the Development of Antiretroviral Therapy in Africa (DART) study,1 which found that little survival benefit was attained with laboratory monitoring as opposed to clinical monitoring alone in the care of HIV-infected patients, have generated a great deal of interest, particularly because it may herald far-reaching changes in the standard of care in resource-poor settings. The potential implications are appealing. DART results not only suggest that a high level of health may be attained and sustained without routine laboratory monitoring, but also that up to one-third more HIV-infected people could be treated with the money saved. Although we unequivocally support any research that can translate into more lives saved, we offer a few notes of caution as the momentum gathers to reshape the standard of care in resource-poor settings based on the DART study. First, we believe that the DART team's provision of free medical care and free diagnostic tests for episodes of illness throughout the trial directly contributed to the presence of high adherence rates, low loss-to-follow-up (LTFU) rates, and relatively high survival rates. In this regard, the importance of developing financing mechanisms that avoid requiring any financial contributions from poor patients cannot be overstated. As policymakers and clinicians adopt nonlaboratory-based treatment guidelines based on DART and expand the number of patients in care, patients' access to ART and other related aspects of medical care must be free.2 Second, the DART study reported high adherence to antiretrovirals (ARVs) and low LTFU rates of only 7% for greater than 3000 patients.1 According to a report in 2008 by the World Health Organization, more than 20% of patients were LTFU in ART programs throughout Africa, Asia, and South America.3 Data from a South London clinic in the United Kingdom showed that the clinic had a 40% LTFU rate.4 These reports show that achieving high adherence and low LTFU rate is not easily achievable except for populations that have access to early support, ARV adherence counseling, and outreach, which is usually the case in study populations such as those enrolled in DART. Third, the quality of clinical monitoring in study-type settings such as DART is generally excellent, given the amount of support and supervision provided. We believe that this quality care is what mainly contributed to the minimal difference in survival between the laboratory and clinical monitoring groups. However, in many resource-constrained settings, access to excellent clinical care is limited. If the DART study does influence policy to shift away from laboratory monitoring to clinical monitoring alone, more resources should be allocated to clinical mentoring of healthcare providers in resource-limited settings to ensure quality clinical assessments. Lastly, although DART focused on projected cost savings without laboratory monitoring and the corresponding increase in the number of patients who could receive ARVs, the standard of care in the developed world remains clinical and laboratory monitoring. It can be argued that a lot of unnecessary laboratory tests are done in developed countries, and studies to evaluate their true benefit must be conducted. However, until that is done, we cannot disregard the potential lives saved with routine laboratory monitoring when done appropriately. Three percent more people in the laboratory monitoring arm of the study survived than people in the clinical monitoring-only arm.1 If DART-inspired clinical guidelines are adopted more broadly, the absolute numbers of patients who will comprise that 3% gap in outcomes will increase, and 2 different standards of care between resource-rich and resource-poor settings will persist. We are optimistic that the results of the DART study will lower barriers and lead to greater access to care for more patients, particularly if the concerns we describe above are addressed as part of revised treatment policies and programs. Shilpa Sayana, MD, MPH Rishi Manchanda, MD, MPH Homayoon Khanlou, MD Jorge Saavedra, MD, MPH Peter Reis Michael Weinstein Department of Medicine, AIDS Healthcare Foundation, Los Angeles, CA" @default.
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• W2080702947 date "2010-01-01" @default.
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• W2080702947 title "Avoid a Different Standard of Care When Applying Results of Development of Antiretroviral Therapy in Africa (DART) Study" @default.
• W2080702947 doi "https://doi.org/10.1097/qai.0b013e3181c79be7" @default.
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