Scale-up of a decentralized HIV treatment programme

Scale-up of a decentralized HIV treatment programme in rural KwaZulu-Natal, South Africa: does rapid expansion affect patient outcomes?

The objective of the study was to describe the scale-up of a decentralized HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population. The programme started delivery of antiretroviral therapy in October 2004. Information on all patients initiated on antiretroviral therapy was captured in the programme database and follow-up status was updated monthly. All adult patients (>/= 16 years) who initiated antiretroviral therapy between October 2004 and September 2008 were included and stratified into 6-month groups. Clinical and sociodemographic characteristics were compared between the groups. Retention in care, mortality, loss to follow-up and virological outcomes were assessed at 12 months post- antiretroviral therapy initiation. A total of 5719 adults initiated on antiretroviral therapy were included (67.9% female). Median baseline CD4+ lymphocyte count was 116 cells/microl (interquartile range, IQR: 53-173). There was an increase in the proportion of women who initiated antiretroviral therapy while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84.0% (95% confidence interval, CI: 82.6-85.3); 10.9% died (95% CI: 9.8-12.0); 3.7% were lost to follow-up (95% CI: 3.0-4.4). Mortality was highest in the first 3 months after antiretroviral therapy initiation: 30.1 deaths per 100 person-years (95% CI: 26.3-34.5). At 12 months 23.0% had a detectable viral load (> 25 copies/ml) (95% CI: 19.5-25.5). Outcomes were not affected by rapid expansion of this decentralized HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services.

Editors’ note: South Africa, home to almost one of every six people living with HIV globally, has the largest public sector antiretroviral therapy programme in the world. Most treatment outcome reports from South Africa and neighbouring countries, with the exception of Malawi, have come from urban treatment cohorts. This study of a decentralized antiretroviral treatment programme in rural KwaZulu Natal presents encouraging findings about treatment scale-up and points the way for needed improvements. The Hlabisa HIV Treatment and Care Programme is delivered through a network of 16 primary health care centres in a subdistrict with extraordinarily high HIV prevalence (50.9% in women 25-29 years and 43.5% in males aged 30-34 years in 2007). The lower 14% loss to follow-up at 12 months may be attributed to the proximity of the clinics to people’s homes and an active tracking system with phone contact followed by home visits by a tracker nurse when necessary. Almost 1 in 4 people had a detectable viral load at 12 months but drug resistance levels were low, suggesting that suboptimal adherence needs to be actively addressed. High mortality in the first 3 months of treatment, particularly among men, speaks to the need for promoting earlier diagnosis and providing ‘positive health, dignity, and prevention’ counselling and care, pending treatment eligibility. This is a good example of how careful monitoring of treatment outcomes can highlight critical programme issues to address as rapid scale-up proceeds.