South Africa is home to 5.7 million people living with h del immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), or approximately 1 in 6 of the world's HIV+ population. (1) It also has the largest public-sector antiretroviral therapy (ART) programme in the world, with an estimated 460 000 individuals established on ART by December 2007. However, as 1.5 million people living with HIV/AIDS in South Africa are estimated to be in need of ART, this figure only equates to 30% coverage. (2) If the ambitious target set under the National Strategic Plan of universal access by 2011 is to be achieved, scale-up of ART services must be intensified. (3,4)
There is good evidence that ART can be delivered effectively in South Africa, with individual virological and immunological responses to ART equivalent to those in high-resourcc settings. (5) Most published evidence relating to ART scale-up in South Africa, however, has come from urban treatment cohorts or from provinces with primarily urban populations. (5-9) Neighbouring countries in southern Africa have also reported programme outcomes, although again based largely on urban cohorts. (10,11) Only the Malawi national programme has reported large-scale data on a predominantly rural population. (12) Delivery of HIV treatment and care to rural communities presents unique challenges, and current ART delivery models may significantly limit the accessibility of ART. (13) To have the greatest impact on public health, HIV treatment programmes will have to be decentralized and integrated into the existing primary health care System. (14) Preliminary evidence from such rural programmes has demonstrated that ART provision in rural communities is feasible, given the appropriate resources and infrastructure. (15,16)
Concern has been raised that the rapid expansion of HIV services will reduce the quality of care for individuals within the programme as capacity and resources are stretched. (17) Characteristics of individuals accessing treatment may change over time, and this in itself may affect overall treatment outcomes. (18) Monitoring treatment outcomes is essential to identify constraints or deficiencies in programme performance, and viral load monitoring may provide warning of adherence problems and of possible development of acquired antiretroviral resistance. (19)
To evaluate a decentralized model of ART delivery in a rural community, we analysed the scale-up of our programme and explored trends in the characteristics of individuals accessing treatment and their outcomes within the first year of treatment.
The Hlabisa HTV Treatment and Care Programme is a partnership between the local Department of Health and the Africa Centre for Health and Population Studies to deliver the South African Comprehensive HIV and AIDS Care, Management and Treatment Plan. (20) It is a decentralized programme of HIV treatment and care delivered through a network of 16 primary health care clinics in the Hlabisa subdistrict of Umkhanyakude district in northern KwaZulu-Natal. The subdistrict covers an arca of 1430 [km.sup.2] and has a population of approximately 220 000, mostly living in rural areas. (21) HIV infection prevalence peaks at 50.9% among females aged 25-29 years and 43.5% among males aged 30-34 years. (22) The programme employs a public health approach to ART delivery aimed at facilitating rapid scale-up of HIV treatment services. (14,23) Support for the programme is provided by the President's Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID).
The programme adheres to the national antiretroviral treatment guidelines, which recommend initiation of ART for adults with stage IV disease as defined by the World Health Organization (WHO) (24) ora CD4+ lymphocyte (CD4 cell) count of < 200 cells/[micro]l. …