Rapid expansion of HIV treatment services in Africa feasible, with good patient outcomes

A massive scale-up of HIV/AIDS treatment programs at urban primary care sites in Zambia has produced favorable patient outcomes, demonstrating that expansion of such programs in sub-Saharan Africa is feasible, with good results, according to a study in the August 16 issue of JAMA, a theme issue on HIV/AIDS.

Jeffrey S.A. Stringer, M.D., of the Centre for Infectious Disease Research in Zambia, Lusaka, and the University of Alabama at Birmingham, presented the findings of the study today at a JAMA media briefing at the International AIDS Conference in Toronto.

Zambia's 11.5 million residents are among the world's poorest and most severely affected by acquired immunodeficiency syndrome (AIDS), according to background information in the article. About 16 percent of the adult population is infected with human immunodeficiency virus 1 (HIV 1), including 22 percent in the capital city Lusaka. In 2003, more than 90,000 Zambians died of HIV disease. Historically, only the wealthiest citizens have had access to antiretroviral therapy (ART) for HIV through private medical practices.

The Zambian Ministry of Health, aiming to provide public access to treatment, in 2002 started pilot ART distribution programs at two of the country's largest hospitals. The program filled almost immediately and in May 2004 expanded to four clinics in the Lusaka Urban District, which were staffed primarily by clinical officers and nurses. In the following 18 months, all fees for patients seeking care were eliminated, ART and laboratory tests were offered for free and the program expanded to 14 additional urban sites. "At the time of program initiation, there was widespread uncertainty that complex, long-term HIV care could be delivered in a setting with so few physicians and so little physical and technical resources," the authors write.

Dr. Stringer and colleagues report on their initial experience with the program and evaluate outcomes among more than 16,000 patients receiving ART at the 18 facilities between April 2004 and Nov. 2005. The study details survival, treatment failure rates and CD4 cell count response, a measure of the state of the immune system. The lower the CD4 count, the more likely a patient with HIV/AIDS is to develop secondary infections or illnesses.

More than 21,755 patients entered the program during the study period, 16,198 of whom received ART. A total of 1,142 patients receiving ART died; of those, 1,120 had a reliable date of death and 792 of those died within the first 90 days of beginning therapy. After the first 90 days, there were five deaths per 100 patient-years, comparable to rates in the developed world. CD4 cell responses also were similar to those in developed nations. Therapy failure was defined as a worsening stage of disease after three months of treatment or a return of CD4 cell counts below pretreatment levels. Of 11,714 patients at risk, 861 failed therapy.

The rapid expansion of the program and its success can be largely attributed to four factors, the researchers report. The leadership and advocacy provided by the Zambian government, demonstrated in its decision to eliminate patient fees, was a key factor in ensuring equal access. Second, although physician shortages prevented medical oversight at every facility, clinical officers and nurses at each site followed strict protocols for patient care. In addition, all patient data is entered into an electronic tracking and outcomes monitoring system, capturing data that assists in individual patient care and overall clinic management. Finally, large financial resources made available by the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) contributed to the program's success.

"Despite the burgeoning availability of ART, HIV prevention remains critical in Zambia, where each year an estimated 100,000 adults and children become infected and an additional 100,000 already infected individuals meet criteria for ART initiation," the authors conclude. "We believe the early success of the Lusaka District ART Program calls for optimism. This experience demonstrates that it is possible, given proper resources and local government commitment, to treat many thousands of people in urban African settings." (JAMA. 2006;296:782-793. Available pre-embargo to the media at www.jamamedia.org)

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Editor's Note: This work was supported by a multicountry grant to the Elizabeth Glaser Pediatric AIDS Foundation from the U.S. Centers for Disease Control and Prevention. Additional investigator salary support is provided by National Institutes of Health grants and an Elizabeth Glaser Pediatric AIDS Foundation grant. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.


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