Viability and Effectiveness of Large-scale HIV Treatment Initiatives in sub-Saharan Africa: Experience from western Kenya

Division of Infectious Diseases, Indiana University-Purdue University Indianapolis, Indianapolis, Indiana, United States
AIDS (Impact Factor: 5.55). 01/2006; 20(1):41-8. DOI: 10.1097/01.aids.0000196177.65551.ea
Source: PubMed


To determine the clinical and immunological outcomes of a cohort of HIV-infected patients receiving antiretroviral therapy.
Retrospective study of prospectively collected data from consecutively enrolled adult HIV-infected patients in eight HIV clinics in western Kenya.
CD4 cell counts, weight, mortality, loss to follow-up and adherence to antiretroviral therapy were collected for the 2059 HIV-positive non-pregnant adult patients treated with antiretroviral drugs between November 2001 and February 2005.
Median duration of follow-up after initiation of antiretroviral therapy was 40 weeks (95% confidence interval, 38-43); 111 patients (5.4%) were documented as deceased and 505 (24.5%) were lost to follow-up. Among 1766 (86%) evaluated for adherence to their antiretroviral regimen, 78% reported perfect adherence at every visit. Although patients with and without perfect adherence gained weight, patients with less than perfect adherence gained 1.04 kg less weight than those reporting perfect adherence (P = 0.059). CD4 cell counts increased by a mean of 109 cells/microl during the first 6 weeks of therapy and increased more slowly thereafter, resulting in overall CD4 cell count increases of 160, 225 and 297 cells/microl at 12, 24, and 36 months respectively. At 1 year, a mean increase of 170 cells/microl was seen among patients reporting perfect adherence compared with 123 cells/microl among those reporting some missed doses (P < 0.001).
Antiretroviral treatment of adult Kenyans in this cohort resulted in significant and persistent clinical and immunological benefit. These findings document the viability and effectiveness of large-scale HIV treatment initiatives in resource-limited settings.

Download full-text


Available from: Kara Wools-Kaloustian
  • Source
    • "Widespread access to testing and treatment facilitated by the President's Emergency Plan for AIDS Relief (PEPFAR; we-do/global-health/hiv-and-aids) have greatly enhanced opportunities to successfully incorporate biomarker procedures into adolescent HIV prevention research designs, since infected individuals identified through testing offered by studies may access free or subsidized HIV treatment and care (Stringer et al., 2006; Wools-Kaloustian et al., 2006, 2009). Moreover , including biomarker outcomes can greatly improve the credibility and legitimacy of HIV prevention research. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Self-report of sexual behavior among adolescents is notoriously inconsistent, yet such measures are commonly used as outcomes for human immunodeficiency virus (HIV) prevention intervention trials. There has been a growing interest in the use of HIV and other sexually transmitted disease biomarkers as more valid measures of intervention impact in high HIV prevalence areas, particularly in sub-Saharan Africa. We examine the challenges, benefits, and feasibility of including HIV and herpes simplex virus type 2 (HSV-2) biomarker data, with details about different data collection and disclosure methods from two adolescent prevention trials in Kenya and Zimbabwe. In Kenya, whole blood samples were collected using venipuncture; adult guardians were present during biomarker procedures and test results were disclosed to participants and their guardians. In contrast, in Zimbabwe, samples were collected using finger pricks for dried blood spots (DBS); guardians were not present during biomarker procedures, and results were not disclosed to participants and/or their guardians. In both countries, prevalence in the study samples was low. Although the standard of care for testing for HIV and other sexually transmitted infections includes disclosure in the presence of a guardian for adolescents under age 18, we conclude that more research about the risks and benefits of disclosure to adolescents in the context of a clinical trial is needed. Notably, current serological diagnosis for HSV-2 has a low positive predictive value when prevalence is low, resulting in an unacceptable proportion of false positives and serious concerns about disclosing test results to adolescents within a trial. We also conclude that the DBS approach is more convenient and efficient than venipuncture for field research, although both approaches are feasible. Manufacturer validation studies using DBS for HSV-2, however, are needed for widespread use.
    Full-text · Article · Mar 2014 · The Journal of Prevention
  • Source
    • "In this study we observed a direct correlation between the two different outcomes (survival and CD4+ T-cell count recovery) and adherence evaluated through our score: our data substantially confirm previous findings [25,26] suggesting that good adherence enhances CD4+ T-cell recovery and decreases mortality. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Aim of our study is to investigate the clinical and immunological outcomes according to first-line HAART adherence in a large cohort of HIV-infected patients in Burkina Faso. A retrospective study was conducted between 2001 and 2009 among patients from two urban medical centers [St. Camille Medical Center (CMSC) and "Pietro Annigoni" Biomolecular Research Center (CERBA)] and 1 in the rural District of Nanoro (St. Camille District Hospital). Socio-demographical and clinical data were analyzed. Adherence was evaluated through a questionnaire investigating 5 key points related to drugs, consultations and blood exams, by assigning 0 to 2 points each up to 10 points overall. Data were collected at baseline and regularly thereafter. Adherence score was considered as a continuous variable and classified in optimal (8-10 points) and sub-optimal (0-7 points). Immunological outcome was evaluated as modification in CD4+ T-cell count over time, while predictors of death were explored by a univariate and multivariate Cox model considering adherence score as a time-varying covariate. A total of 625 patients were included: 455 (72.8%) were females, the median age was 33.3 (IQR 10.2) years, 204 (32.6.%) were illiterates, the median CD4+ T-cell count was 149 (IQR 114) cells/mul at baseline. At the end of the observation period we recorded 60/625 deaths and 40 lost to follow-up. The analysis of immunological outcomes showed a significant variation in CD4+ T-cell count between M12 and M24 only for patients with optimal adherence (Delta=78.2, p<0.001), with a significant Delta between the two adherence groups at M24 (8-10 vs 0-7, Delta=53.8, p=0.004). Survival multivariate analysis revealed that covariates significantly related to death included being followed at CERBA (urban area) or Nanoro (rural area), and receiving a regimen not including fixed dose combinations, (p=0.024, p=0.001 and p<0.001 respectively); conversely, an increasing adherence score as well as an optimal adherence score were significantly related to survival (p<0.001). Adherence to HAART remains pivotal to build up a good therapeutic outcome. Our results confirm that, according to our adherence system evaluation, less adherent patients have a higher risk of death and of inadequate CD4+ count recovery.
    Full-text · Article · Mar 2014 · BMC Infectious Diseases
  • Source
    • "Successful delivery of ART in Africa is possible in adults and children as evidenced by good clinical and immunological responses [8,9]. However, disruptions in ART can lead to antiretroviral resistance resulting in virologic failure and subsequent immunologic and clinical failure [6-14]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Widespread violence followed the 2007 presidential elections in Kenya resulting in the deaths of a reported 1,133 people and the displacement of approximately 660,000 others. At the time of the crisis the United States Agency for International Development-Academic Model Providing Access to Healthcare (USAID-AMPATH) Partnership was operating 17 primary HIV clinics in western Kenya and treating 59,437 HIV positive patients (23,437 on antiretroviral therapy (ART)). This case study examines AMPATH's provision of care and maintenance of patients on ART throughout the period of disruption. This was accomplished by implementing immediate interventions including rapid information dissemination through the media, emergency hotlines and community liaisons; organization of a Crisis Response leadership team; the prompt assembly of multidisciplinary teams to address patient care, including psychological support staff (in clinics and in camps for internally displaced persons (IDP)); and the use of the AMPATH Medical Records System to identify patients on ART who had missed clinic appointments. These interventions resulted in the opening of all AMPATH clinics within five days of their scheduled post-holiday opening dates, 23,949 patient visits in January 2008 (23,259 previously scheduled), uninterrupted availability of antiretrovirals at all clinics, treatment of 1,420 HIV patients in IDP camps, distribution of basic provisions, mobilization of outreach services to locate missing AMPATH patients and delivery of psychosocial support to 300 staff members and 632 patients in IDP camps. Key lessons learned in maintaining the delivery of HIV care in a crisis situation include the importance of advance planning to develop programs that can function during a crisis, an emphasis on a rapid programmatic response, the ability of clinics to function autonomously, patient knowledge of their disease, the use of community and patient networks, addressing staff needs and developing effective patient tracking systems.
    Full-text · Article · Dec 2013 · Conflict and Health
Show more