Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment.

Hdl Handle:
http://hdl.handle.net/10144/18920
Title:
Scaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment.
Authors:
Ferradini, L; Jeannin, A; Pinoges, L; Izopet, J; Odhiambo, D; Mankhambo, L; Karungi, G; Szumilin, E; Balandine, S; Fedida, G; Carrieri, M P; Spire, B; Ford, N; Tassie, J; Guerin, P J J; Brasher, C
Journal:
Lancet
Abstract:
BACKGROUND: The recording of outcomes from large-scale, simplified HAART (highly active antiretroviral therapy) programmes in sub-Saharan Africa is critical. We aimed to assess the effectiveness of such a programme held by Médecins Sans Frontières (MSF) in the Chiradzulu district, Malawi. METHODS: We scaled up and simplified HAART in this programme since August, 2002. We analysed survival indicators, CD4 count evolution, virological response, and adherence to treatment. We included adults who all started HAART 6 months or more before the analysis. HIV-1 RNA plasma viral load and self-reported adherence were assessed on a subsample of patients, and antiretroviral resistance mutations were analysed in plasma with viral loads greater than 1000 copies per mL. Analysis was by intention to treat. FINDINGS: Of the 1308 patients who were eligible, 827 (64%) were female, the median age was 34.9 years (IQR 29.9-41.0), and 1023 (78%) received d4T/3TC/NVP (stavudine, lamivudine, and nevirapine) as a fixed-dose combination. At baseline, 1266 individuals (97%) were HAART-naive, 357 (27%) were at WHO stage IV, 311 (33%) had a body-mass index of less than 18.5 kg/m2, and 208 (21%) had a CD4 count lower than 50 cells per muL. At follow-up (median 8.3 months, IQR 5.5-13.1), 967 (74%) were still on HAART, 243 (19%) had died, 91 (7%) were lost to follow-up, and seven (0.5%) discontinued treatment. Low body-mass index, WHO stage IV, male sex, and baseline CD4 count lower than 50 cells per muL were independent determinants of death in the first 6 months. At 12 months, the probability of individuals still in care was 0.76 (95% CI 0.73-0.78) and the median CD4 gain was 165 (IQR 67-259) cells per muL. In the cross-sectional survey (n=398), 334 (84%) had a viral load of less than 400 copies per mL. Of several indicators measuring adherence, self-reported poor adherence (<80%) in the past 4 days was the best predictor of detectable viral load (odds ratio 5.4, 95% CI 1.9-15.6). INTERPRETATION: These data show that large numbers of people can rapidly benefit from antiretroviral therapy in rural resource-poor settings and strongly supports the implementation of such large-scale simplified programmes in Africa.
Affiliation:
Epicentre, Paris, France. msffr.comed@online.com.kh
Publisher:
Elsevier
Issue Date:
22-Apr-2006
URI:
http://hdl.handle.net/10144/18920
DOI:
10.1016/S0140-6736(06)68580-2
PubMed ID:
16631912
Additional Links:
http://www.thelancet.com
Language:
en
ISSN:
1474-547X
Appears in Collections:
Health Politics

Full metadata record

DC FieldValue Language
dc.contributor.authorFerradini, L-
dc.contributor.authorJeannin, A-
dc.contributor.authorPinoges, L-
dc.contributor.authorIzopet, J-
dc.contributor.authorOdhiambo, D-
dc.contributor.authorMankhambo, L-
dc.contributor.authorKarungi, G-
dc.contributor.authorSzumilin, E-
dc.contributor.authorBalandine, S-
dc.contributor.authorFedida, G-
dc.contributor.authorCarrieri, M P-
dc.contributor.authorSpire, B-
dc.contributor.authorFord, N-
dc.contributor.authorTassie, J-
dc.contributor.authorGuerin, P J J-
dc.contributor.authorBrasher, C-
dc.date.accessioned2008-02-21T16:19:06Z-
dc.date.available2008-02-21T16:19:06Z-
dc.date.issued2006-04-22-
dc.identifier.citationScaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment. 2006, 367 (9519):1335-42 Lanceten
dc.identifier.issn1474-547X-
dc.identifier.pmid16631912-
dc.identifier.doi10.1016/S0140-6736(06)68580-2-
dc.identifier.urihttp://hdl.handle.net/10144/18920-
dc.description.abstractBACKGROUND: The recording of outcomes from large-scale, simplified HAART (highly active antiretroviral therapy) programmes in sub-Saharan Africa is critical. We aimed to assess the effectiveness of such a programme held by Médecins Sans Frontières (MSF) in the Chiradzulu district, Malawi. METHODS: We scaled up and simplified HAART in this programme since August, 2002. We analysed survival indicators, CD4 count evolution, virological response, and adherence to treatment. We included adults who all started HAART 6 months or more before the analysis. HIV-1 RNA plasma viral load and self-reported adherence were assessed on a subsample of patients, and antiretroviral resistance mutations were analysed in plasma with viral loads greater than 1000 copies per mL. Analysis was by intention to treat. FINDINGS: Of the 1308 patients who were eligible, 827 (64%) were female, the median age was 34.9 years (IQR 29.9-41.0), and 1023 (78%) received d4T/3TC/NVP (stavudine, lamivudine, and nevirapine) as a fixed-dose combination. At baseline, 1266 individuals (97%) were HAART-naive, 357 (27%) were at WHO stage IV, 311 (33%) had a body-mass index of less than 18.5 kg/m2, and 208 (21%) had a CD4 count lower than 50 cells per muL. At follow-up (median 8.3 months, IQR 5.5-13.1), 967 (74%) were still on HAART, 243 (19%) had died, 91 (7%) were lost to follow-up, and seven (0.5%) discontinued treatment. Low body-mass index, WHO stage IV, male sex, and baseline CD4 count lower than 50 cells per muL were independent determinants of death in the first 6 months. At 12 months, the probability of individuals still in care was 0.76 (95% CI 0.73-0.78) and the median CD4 gain was 165 (IQR 67-259) cells per muL. In the cross-sectional survey (n=398), 334 (84%) had a viral load of less than 400 copies per mL. Of several indicators measuring adherence, self-reported poor adherence (<80%) in the past 4 days was the best predictor of detectable viral load (odds ratio 5.4, 95% CI 1.9-15.6). INTERPRETATION: These data show that large numbers of people can rapidly benefit from antiretroviral therapy in rural resource-poor settings and strongly supports the implementation of such large-scale simplified programmes in Africa.en
dc.language.isoenen
dc.publisherElsevier-
dc.relation.urlhttp://www.thelancet.com-
dc.rightsReproduced on this site with permission of Elsevier Ltd. Please see www.thelancet.com for further relevant comment.en
dc.subject.meshAdulten
dc.subject.meshAntiretroviral Therapy, Highly Activeen
dc.subject.meshCD4 Lymphocyte Counten
dc.subject.meshCross-Sectional Studiesen
dc.subject.meshFemaleen
dc.subject.meshHIV Infectionsen
dc.subject.meshHumansen
dc.subject.meshMalawien
dc.subject.meshMaleen
dc.subject.meshPatient Complianceen
dc.subject.meshRural Healthen
dc.subject.meshTreatment Outcomeen
dc.subject.meshViral Loaden
dc.titleScaling up of highly active antiretroviral therapy in a rural district of Malawi: an effectiveness assessment.en
dc.contributor.departmentEpicentre, Paris, France. msffr.comed@online.com.khen
dc.identifier.journalLanceten

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