Outcomes After Two Years of Providing Antiretroviral Treatment in Khayelitsha, South Africa

David Coetzee; Katherine Hildebrand; Andrew Boulle; Gary Maartens; Francoise Louis; Veliswa Labatala; Hermann Reuter; Nonthutuzelo Ntwana; Eric Goemaere


AIDS. 2004;18(6) 

In This Article

Abstract and Introduction

Background: A community-based antiretroviral therapy (ART) programme was established in 2001 in a South African township to explore the operational issues involved in providing ART in the public sector in resource-limited settings and demonstrate the feasibility of such a service.
Methods: Data was analysed on a cohort of patients with symptomatic HIV disease and a CD4 lymphocyte count < 200 × 106 cells/l. The programme used standardized protocols (using generic medicines whenever possible), a team-approach to clinical care and a patient-centred approach to promote adherence.
Results: Two-hundred and eighty-seven adults naive to prior ART were followed for a median duration of 13.9 months. The median CD4 lymphocyte count was 43 × 106 cells/l at initiation of treatment, and the mean log10 HIV RNA was 5.18 copies/ml. The HIV RNA level was undetectable (< 400 copies/ml) in 88.1, 89.2, 84.2, 75.0 and 69.7% of patients at 3, 6, 12, 18 and 24 months respectively. The cumulative probability of remaining alive was 86.3% at 24 months on treatment for all patients, 91.4% for those with a baseline CD4 lymphocyte count ≥ 50 × 106 cells/l, and 81.8% for those with a baseline CD4 lymphocyte count < 50 × 106 cells/l. The cumulative probability of changing a single antiretroviral drug by 24 months was 15.1% due to adverse events or contraindications, and 8.4% due to adverse events alone.
Conclusions: ART can be provided in resource-limited settings with good patient retention and clinical outcomes. With responsible implementation, ART is a key component of a comprehensive response to the epidemic in those communities most affected by HIV.

The benefits of antiretroviral therapy (ART) at an individual level are incontrovertible.[1,2] The potential benefits at a population level of successful ART programmes in those countries worst affected by the HIV pandemic are widely argued.[3,4] Even where universal access to ART for those who could benefit from it is not possible, many have argued strongly for ART to be an important component of an integrated response to the epidemic in resource-limited countries.[3,5]

The publication by the World Health Organization (WHO) of guidelines for the scaling up of antiretroviral therapy in resource-limited settings[6] signals a convergence of clinical thinking that should, in theory, facilitate the rapid expansion of ART in these settings. Evidence of the effectiveness of public sector ART programmes in those countries with the largest HIV-morbidity and mortality burdens has, however, been slow in emerging. Many interventions have relied on private or out-of-pocket funding of treatment,[7] and where policies exist to provide treatment in the public sector, uptake has been slower than anticipated.[8]

The aim of this analysis is to present the early clinical outcomes for adults in a public-sector ART programme in a primary care setting in a poor urban community in South Africa.