Academic journal article Bulletin of the World Health Organization

Antiretroviral Therapy and Early Mortality in South Africa/Traitement Antiretroviral et Mortalite Precoce En Afrique Du Sud/Tratamiento Antirretroviral Y Mortalidad Temprana En Sudafrica

Academic journal article Bulletin of the World Health Organization

Antiretroviral Therapy and Early Mortality in South Africa/Traitement Antiretroviral et Mortalite Precoce En Afrique Du Sud/Tratamiento Antirretroviral Y Mortalidad Temprana En Sudafrica

Article excerpt

Introduction

The national antiretroviral treatment (ART) programme in South Africa was launched in April 2004. (1) However, for some years prior to this, demonstration projects had provided ART to HIV-infected individuals with advanced disease through government health services. Several projects were located in the Western Cape Province which, as a result, is able to report on outcomes up to 4 years after initiation of therapy. The first such project began providing ART in Khayelitsha in May 2001, (2,3) followed by a project in Gugulethu in September 2002 (4-6)

Since inception, the clinical guidelines and approaches to monitoring used in the Western Cape Province have been in line with those recommended by WHO. (7-9) The treatment setting is reflective of public sector health services in South Africa. A description of outcomes 5 years into this provincial programme, and after significant scaling-up of care, has relevance to what can be anticipated in South Africa and other similar settings in the region.

This paper demonstrates that robust and useful information can be generated using a basics-first, paper-based monitoring system, as recommended by WHO. (10) There are some sites in the province that collect clinical data electronically and enhance these data for cohort surveillance and research. These are designated as sentinel sites and address particular clinical and epidemiological questions. This takes pressure off the remaining sites from having to institute complex monitoring systems and ensures that in the majority of sites only the information essential for management and programme assessment is collected.

The aim of this paper is to describe the key clinical outcomes in the Western Cape provincial ART programme, in patients on therapy for up to 4 years, and the evolution of the programme over a 5-year period. Secondary aims are to demonstrate the field utility of the WHO monitoring guidelines and the feasibility of scaling-up services through primary-care sites.

Programme description

The first project to routinely offer ART in the public sector and on a district-wide basis in South Africa was started in 2001 as a partnership between the provincial government and Medecins Sans Frontieres in the Cape Town township of Khayelitsha. At that time, several local clinicians had already been involved in ART provision through clinical studies and private funding and were able to support this and subsequent initiatives. These early sites can be considered as "innovator sites" in as far as they were able to grapple with many of the logistics of setting up services in anticipation of a more rapid scaling-up of ART services. By the time the national programme was launched in South Africa in April 2004, there were 16 discrete sites offering ART in the province, eight of which were in primary care. At this time there were 2327 patients receiving ART. By the end of March 2006, there were 16 234 patients receiving ART (87% adults) across 43 sites, the majority being treated in primary-care settings (67% in clinics and community health centres, and 13% in district hospitals). Enrolment increased steadily over this time to reach 1000 patients per month, with seasonal decreases in enrolment each December (Fig. 1 and Fig. 2). Care was first offered as part of the primary-care HIV intervention for children in 2002, with follow-up for children in this analysis extending to 3 years. Children were defined as patients starting ART under the age of 14 years.

[FIGURE 1 OMITTED]

[FIGURE 2 OMITTED]

Patients were considered eligible for ART if they had a stage IV illness (excluding extrapulmonary tuberculosis) or a CD4 count less than 200 cells/ [micro]l. The adult regimens used throughout comprised two nucleotide reverse transcriptase inhibitors (NRTIs) and one non-nucleotide reverse transcriptase inhibitor (NNRTI). Initially, the NRTI backbone in Khayelitsha comprised zidovudine and lamivudine, but was later changed to stavudine and lamivudine in line with the national programme. …

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