Management of HIV in resource limited settings

The present review addresses recent developments in management of the HIV epidemic in resource limited settings (RLS). Access to antiretroviral therapy (ART) by an estimated 2.5 million persons in RLS from 2002 to the end of 2007 was enabled by the combination of inexpensive rapid diagnostics and therapy for HIV and the mobilization of substantial resources from the developed world.

Rates of retention in care and immunological responses to ART in RLS appear to be similar to those in developed countries. Higher rates of death within 3 months of starting ART in RLS than in developed countries are not fully understood and must be addressed. Improved management of opportunistic infections, such as tuberculosis and cryptococcal meningitis, is being vigorously pursued, in part because patients must survive their initial opportunistic infection to benefit from ART. Prevention of reactivation of latent tuberculosis with isoniazid and simplified treatment of cryptococcal meningitis with high-dose fluconazole are among the highest priorities. The optimal timing for starting ART during opportunistic infections remains unclear, with starkly conflicting findings in two studies, and may vary among specific opportunistic infections.

Given the massive resources that are available for implementation of ART and HIV care in RLS, research to optimize their impact is urgently needed.