ArticlesAssessment of a pilot antiretroviral drug therapy programme in Uganda: patients' response, survival, and drug resistance
Introduction
Intolerance of the global inequities in AIDS care continues to grow. However, little information is available to guide development and implementation of antiretroviral drug programmes in developing countries. The use of antiretroviral therapy is expected to increase in resource-limited settings as drug prices fall and international agencies increase funding for AIDS programmes.1, 2, 3 At the same time, major challenges exist in the development of infrastructure needed to ensure uninterrupted drug stocks and the appropriate, safe, and effective use of these drugs.4, 5, 6, 7 The UNAIDS HIV Drug Access Initiative (DAI) was a pilot programme developed in 1997 to increase access to AIDS care and drugs in Uganda, Côte d'Ivoire, Chile, and Vietnam.2 The UNAIDS/Uganda Ministry of Health DAI pilot project, one of the first antiretroviral programmes in Africa, began in June 1998.
UNAIDS and the government of Uganda developed terms of agreement for the DAI, which included hiring a project coordinator and establishing an advisory board within the Uganda Ministry of Health. The advisory board conducted general oversight and policy development for the DAI. The initiative established national treatment guidelines, developed information materials, and trained and educated health-care providers on AIDS care. Patients and their families were responsible for paying for all their medical care, drugs, and laboratory tests. The US Centers for Disease Control and Prevention (CDC), in collaboration with the Ministry of Health and UNAIDS, assessed the virological and immunological response to treatment, sustainability of treatment, survival, and emergence of drug resistance among patients using the DAI. We present the results here.
Section snippets
Background
Five health-care facilities were accredited to provide antiretroviral drug treatment through the initiative; all were in or near the capital city of Kampala. Accreditation standards included having trained medical staff, a laboratory, counselling services, secure drug storage, and sufficient resources for the purchase of the first instalment of drugs. The experience and capacity of the participating centres varied greatly, although all represented the highest level of medical care available in
Patients and treatment regimens
912 patients were enrolled in the DAI at the five centres. This analysis included the 476 individuals who enrolled in the DAI at three centres evaluated: Nsambya Hospital (n=286), Mildmay HIV Care and Rehabilitation Center (n=157), and Mulago Hospital (n=33; table 1). Not included in this analysis were 424 patients started at JCRC and 12 at Mengo Hospital. For comparison, baseline characteristics of patients at JCRC were similar to those in this analysis with regard to age (median 37, p=0·3),
Discussion
This report summarises a systematic assessment of one of the first national programmes aimed at increasing access to antiretroviral therapy in Africa. This pilot programme showed that, through modest increases of existing resources, an effective system for drug procurement, distribution, and accountability could be implemented and maintained. This accomplishment led to an uninterrupted supply of drugs that supported sustainable management of patients, despite the often stated financial,
References (28)
- et al.
Randomised placebo-controlled trial of ritonavir in advanced HIV-1 disease
Lancet
(1998) HIV/AIDS treatment for millions
Science
(2001)Access to drugs: UNAIDS technical update
(1998)Companies, donors pledge to close gap in AIDS treatment
Science
(2000)Antiretrovirals for developing world
Lancet
(1998)- et al.
The challenge of providing effective care for HIV/AIDS in Africa
AIDS
(1997) - et al.
Antiretroviral treatment in Africa
AIDS
(1997) - et al.
Community-based approaches to HIV treatment in resource-poor settings
Lancet
(2001) - et al.
A rapid method for simultaneous detection of phenotypic resistance to inhibitors of protease and reverse transcriptase in recombinant human immunodeficiency virus type 1 isolates from patients treated with antiretroviral drugs
Antimicrob Agents Chemother
(1998) - et al.
Establishment of biologically-relevant cutoffs for HIV drug resistance testing
AIDS
(2000)
Longitudinal data analysis using generalized linear models
Biometrics
Multiple imputations for nonresponse in surveys
AVANTI 2: randomized, double-blind trial to evaluate the efficacy and safety of zidovudine plus lamivudine versus zidovudine plus lamivudine plus indinavir in HIV-infected antiretroviral-naïve patients
AIDS
A randomized, double-blind trial comparing combinations of nevirapine, didanosine, and zidovudine for HIV-infected patients: the INCAS trial
JAMA
Cited by (277)
Determinants of survival in HIV patients receiving antiretroviral therapy in Goma, Democratic Republic of Congo
2014, Revue d'Epidemiologie et de Sante PubliqueA Combined Fabrication and Instrumentation Platform for Sample Preparation
2014, Journal of Laboratory AutomationAltered phenotype and function of NK cells infiltrating Human Papillomavirus (HPV)-associated genital warts during HIV infection
2014, Clinical ImmunologyCitation Excerpt :We also found that wart-derived CD56dimCD16 + NK cells from HIV + women showed impaired degranulation compared to those from HIV − women. Following HAART initiation, most HIV + individuals show a gradual rise in CD4 T cell counts, although many do not attain pre-infection CD4 counts and remain immune-suppressed [28,29]. Approximately 7–20% of HIV + individuals who have initiated HAART have been reported to have suboptimal immune reconstitution despite almost complete viral suppression [30–32] and this variability is dependent on the duration of HAART [33].
Which strategy for ART in resource-limited settings
2014, The Lancet HIVOutcomes of the Botswana national HIV/AIDS treatment programme from 2002 to 2010: A longitudinal analysis
2014, The Lancet Global HealthCitation Excerpt :Several studies3–15 have shown the successful implementation of ART programmes in low-income and middle-income countries with overall outcomes that are much the same as in high-income countries. Most reports of ART outcomes, however, have come from select cohorts that might not be indicative of national programme conditions.6,8,16–20 Additionally, most reports have captured national longitudinal outcome data for patients receiving ART for only a few years.