ArticlesMortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study
Introduction
Antiretroviral therapy (ART) is the most effective clinical intervention for reduction of mortality in people with HIV-1 infection. It is increasingly available in the developing countries where 90% of HIV-infected people live, including 63% in Africa.1 However, despite substantial efforts, most HIV-infected people in Africa who would benefit from ART do not have access to it.1 Availability in many areas is constrained by the high cost of medication,2, 3, 4 inadequate numbers of trained health-care providers,5, 6 poorly equipped clinics,7 and distance to health centres.8, 9 Effective ART programmes require high adherence to medication,10 attention to potential drug toxicity, and continuing diagnosis and treatment of opportunistic infections. Ideally, programmes in Africa would provide these services with limited use of physicians and minimum transportation requirements.5 Use of trained lay providers to deliver ART to HIV-infected people at their homes, collect standard health information, and refer patients for selected symptoms could potentially avoid adherence problems stemming from inadequate transportation to clinics and could reduce crowding at health centres.
Although several studies provide information about survival and changes in immunological and virological markers during ART in patients in Africa,11 an assessment of ART effectiveness requires a comparison group and a carefully followed up cohort because randomised trials would be unethical.12, 13 Data for effectiveness of highly active antiretroviral therapy (HAART) from developed countries are few because contemporaneous comparison groups were taking dual treatment at the time HAART became available. In Africa, initial introduction of ART has usually been as HAART. Insight into the effectiveness of HAART in Africa could enable improved decision making by individuals, governments, and donor agencies.
We analysed data from two prospective cohort studies in rural Uganda—the first of co-trimoxazole prophylaxis and the second of HAART. The main purpose of the randomised HAART study was to evaluate three different treatment monitoring strategies. Data aggregated across monitoring groups were used to assess the effect of a home-based ART programme on mortality, hospital admissions, and orphanhood in people with HIV and their families. We assessed the effect of adding HAART to co-trimoxazole prophylaxis and the effect of HAART and co-trimoxazole compared with the time before either intervention.
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Participants and study design
HIV-infected participants (18 years or older) at the Tororo Branch of The AIDS Support Organisation (TASO), including those from Tororo, Busia, and Mbale districts in Uganda were enrolled. In study period 1, initiated in April, 2001, we followed up participants with home visits for a median of 5 months (figure 1). In study period 2, all participants with HIV without previous adverse reactions to sulfonamides were provided daily co-trimoxazole (160 mg of trimethoprim and 800 mg of
Results
Figure 1 shows the study profile. Age and median CD4-cell count differed across study periods (table 1). Age and sex were similar for participants who newly enrolled during period 3 and those who had also participated in period 2 (data not shown); however, median CD4-cell count for newly enrolled participants in period 3 was lower (122 cells per μL vs 143 cells per μL, p=0·02). Median follow-up before co-trimoxazole was 154 (IQR 147–161) days, during co-trimoxazole was 532 (488–542) days, and
Discussion
A home-based ART and co-trimoxazole programme was associated with a greater than 90% reduction in mortality in adults with HIV living in rural Uganda. These results were achieved even though no routine clinic visits were scheduled after initial enrolment, and home visits were provided by trained lay providers. Provision of ART to adults was also associated with a large reduction in mortality in their HIV-negative children, and with substantial reductions in the rate of orphanhood.
The overall
References (33)
- et al.
Scaling up access to antiretroviral treatment in southern Africa: who will do the job?
Lancet
(2004) - et al.
Long-term effectiveness of potent antiretroviral therapy in preventing AIDS and death: a prospective cohort study
Lancet
(2005) - et al.
Effect of co-trimoxazole prophylaxis, antiretroviral therapy, and insecticide-treated bednets on the frequency of malaria in HIV-1- infected adults in Uganda: a prospective cohort study
Lancet
(2006) - et al.
Adherence to antiretroviral therapy in a home-based AIDS care programme in rural Uganda
Lancet
(2006) - et al.
Effect of breastfeeding on mortality among HIV-1 infected women: a randomised trial
Lancet
(2001) AIDS Epidemic Update
- et al.
Free Antiretrovirals must not be restricted only to treatment-naive patients
PLoS Med
(2005) - et al.
Antiretroviral therapy in public and private routine health care clinics in Cameroon: lessons from the Douala antiretroviral (DARVIR) initiative
Clin Infect Dis
(2005) - et al.
Evaluation of antiretroviral therapy results in a resource-poor setting in Blantyre, Malawi
Trop Med Int Health
(2005) - et al.
Antiretroviral treatment roll-out in a resource-constrained setting: capitalizing on nursing resources in Botswana
Bull World Health Organ
(2007)
Access to basic HIV/AIDS related clinical services in Uganda: results of a nationally-representative health facility survey
AIDS Public Policy J
Planning for health infrastructure in Uganda: where is the need?
Simplifying and adapting antiretroviral treatment in resource-poor settings: a necessary step to scaling-up
AIDS
Non-adherence to highly active antiretroviral therapy predicts progression to AIDS
AIDS
Lessons learned from use of highly active antiretroviral therapy in Africa
Clin Infect Dis
The independent effect of highly active therapy on severe opportunistic disease incidence and mortality in HIV-infected adults in Côte d'Ivoire
Antivir Ther
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