 |
|
Rapid Scale-up of Antiretroviral Therapy at Primary Care Sites in Zambia
Feasibility and Early Outcomes
Jeffrey S. A. Stringer, MD;
Isaac Zulu, MD, MPH;
Jens Levy, MS;
Elizabeth M. Stringer, MD;
Albert Mwango, MD;
Benjamin H. Chi, MD;
Vilepe Mtonga, MD;
Stewart Reid, MD, MPH;
Ronald A. Cantrell, MPH;
Marc Bulterys, MD, PhD;
Michael S. Saag, MD;
Richard G. Marlink, MD;
Alwyn Mwinga, MD;
Tedd V. Ellerbrock, MD;
Moses Sinkala, MD, MPH
JAMA. 2006;296:782-793.
Context The Zambian Ministry of Health has scaled-up human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) care and treatment services at primary care clinics in Lusaka, using predominately nonphysician clinicians.
Objective To report on the feasibility and early outcomes of the program.
Design, Setting, and Patients Open cohort evaluation of antiretroviral-naive adults treated at 18 primary care facilities between April 26, 2004, and November 5, 2005. Data were entered in real time into an electronic patient tracking system.
Intervention Those meeting criteria for antiretroviral therapy (ART) received drugs according to Zambian national guidelines.
Main Outcome Measures Survival, regimen failure rates, and CD4 cell response.
Results We enrolled 21 755 adults into HIV care, and 16 198 (75%) started ART. Among those starting ART, 9864 (61%) were women. Of 15 866 patients with documented World Health Organization (WHO) staging, 11 573 (73%) were stage III or IV, and the mean (SD) entry CD4 cell count among the 15 336 patients with a baseline result was 143/µL (123/µL). Of 1142 patients receiving ART who died, 1120 had a reliable date of death. Of these patients, 792 (71%) died within 90 days of starting therapy (early mortality rate: 26 per 100 patient-years), and 328 (29%) died after 90 days (post-90-day mortality rate: 5.0 per 100 patient-years). In multivariable analysis, mortality was strongly associated with CD4 cell count between 50/µL and 199/µL (adjusted hazard ratio [AHR], 1.4; 95% confidence interval [CI], 1.0-2.0), CD4 cell count less than 50/µL (AHR, 2.2; 95% CI, 1.5-3.1), WHO stage III disease (AHR, 1.8; 95% CI, 1.3-2.4), WHO stage IV disease (AHR, 2.9; 95% CI, 2.0-4.3), low body mass index (<16; AHR,2.4; 95% CI, 1.8-3.2), severe anemia (<8.0 g/dL; AHR, 3.1; 95% CI, 2.3-4.0), and poor adherence to therapy (AHR, 2.9; 95% CI, 2.2-3.9). Of 11 714 patients at risk, 861 failed therapy by clinical criteria (rate, 13 per 100 patient-years). The mean (SD) CD4 cell count increase was 175/µL (174/µL) in 1361 of 1519 patients (90%) receiving treatment long enough to have a 12-month repeat.
Conclusion Massive scale-up of HIV and AIDS treatment services with good clinical outcomes is feasible in primary care settings in sub-Saharan Africa. Most mortality occurs early, suggesting that earlier diagnosis and treatment may improve outcomes.
Author Affiliations: Schools of Medicine and Public Health, University of Alabama at Birmingham, Birmingham (Drs J. S. A. Stringer, E. M. Stringer, Chi, Reid, and Saag and Mr Cantrell); Centre for Infectious Disease Research in Zambia, Lusaka (Drs J. S. A. Stringer, Zulu, E. M. Stringer, Chi, and Reid and Messrs Levy and Cantrell); University Teaching Hospital, Lusaka, Zambia (Dr Zulu); School of Public Health, University of North Carolina, Chapel Hill (Mr Levy); Zambian Ministry of Health, Lusaka, Zambia (Drs Mwango, Mtonga, and Sinkala); US Centers for Disease Control and Prevention, Global AIDS Program, Lusaka, Zambia (Drs Bulterys and Mwinga); Elizabeth Glaser Pediatric AIDS Foundation, Santa Monica, Calif (Dr Marlink); US Centers for Disease Control and Prevention, Global AIDS Program, Atlanta, Ga (Dr Ellerbrock); and Lusaka Urban District Health Management Board, Lusaka, Zambia (Dr Sinkala).
RELATED ARTICLE
Scale-up of Voluntary HIV Counseling and Testing in Kenya
Elizabeth Marum, Miriam Taegtmeyer, and Kenneth Chebet
JAMA. 2006;296(7):859-862.
EXTRACT
| FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Micronutrient supplementation has limited effects on intestinal infectious disease and mortality in a Zambian population of mixed HIV status: a cluster randomized trial
Kelly et al.
Am. J. Clin. Nutr. 2008;88:1010-1017.
ABSTRACT
| FULL TEXT
Effects of Early, Abrupt Weaning on HIV-free Survival of Children in Zambia
Kuhn et al.
NEJM 2008;359:130-141.
ABSTRACT
| FULL TEXT
Efficacy of antiretroviral therapy in Africa: effect on immunological and virological outcome measures - a meta-analysis
Hammond and Harry
Int J STD AIDS 2008;19:291-296.
ABSTRACT
| FULL TEXT
Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges?
Boulle and Ford
Postgrad. Med. J. 2008;84:225-227.
FULL TEXT
Rapid Expansion of the Health Workforce in Response to the HIV Epidemic
Samb et al.
NEJM 2007;357:2510-2514.
FULL TEXT
Scaling up antiretroviral therapy in developing countries: what are the benefits and challenges?
Boulle and Ford
Sex. Transm. Infect. 2007;83:503-505.
FULL TEXT
Clinical Outcomes and CD4 Cell Response in Children Receiving Antiretroviral Therapy at Primary Health Care Facilities in Zambia
Bolton-Moore et al.
JAMA 2007;298:1888-1899.
ABSTRACT
| FULL TEXT
The Science of Large-Scale Change in Global Health
McCannon et al.
JAMA 2007;298:1937-1939.
FULL TEXT
Challenges in the Prevention, Diagnosis, and Treatment of Malaria in Human Immunodeficiency Virus Infected Adults in Sub-Saharan Africa
Brentlinger et al.
Arch Intern Med 2007;167:1827-1836.
ABSTRACT
| FULL TEXT
Zidovudine Inhibits Thymidine Phosphorylation in the Isolated Perfused Rat Heart
Susan-Resiga et al.
Antimicrob. Agents Chemother. 2007;51:1142-1149.
ABSTRACT
| FULL TEXT
What's new in the other general journals.
Fister
BMJ 2006;333:437-438.
FULL TEXT
|
