Township project is a model for care in resource poor settings

A poster from Medecins sans Frontiers (MSF) describes their rigorous selection procedure, adherence support and excellent outcome of Africa’s best known – and model – pilot antiretroviral programme, in Khayelitsha, South Africa. [1]

Khayelitsha is a township outside Cape Town with approximately 500,000 inhabitants of which 10% are estimated to be HIV-positive. The choice of the township by MSF “…was in itself an opportunity to prove that an ART programme can be undertaken in even the poorest conditions in a primary health care setting.” [2] MSF began its project there in 1999 and the antiretroviral programme was initiated in May 2001.

Eligibility for the programme is based both on medical criteria – WHO stage III/IV and symptomatic HIV/AIDS – and additional criteria including a community assistant to help with adherence, disclosure of HIV status, residency in Khayelitsha and prompt attendance to three appointments over at least four months.

Each candidate’s folder is presented anonymously to a selection committee comprising different community representatives including people living with HIV. All services, including antiretrovirals, standard monitoring and OI management, are provided free and generic drugs are used as far as possible. The programme takes a multidisciplinary approach to healthcare delivery, and adherence support is rooted firmly in the community working with the Treatment Action Campaign.

The investigators presented results for 288 patients of which 70% were women, with a median age of 31 years, a median CD4 count of 42 cells/mm3, a median viral load of 5.2 logs and 52% with AIDS on initiation of therapy.

They report 84.3% survival at 18 months on treatment despite low median CD4 cell count on initiation and a mean increase in CD4 of 221 cells/mm3 per year. Adherence is excellent with patients reporting taking 95% of their doses. An impressive 90% of patients had undetectable viral loads at three months and 83% at one year.

A research letter from MSF published in the September issue of AIDS reporting polled results from seven projects in resource poor settings (including the Khayelitsha project) describes similar findings – with a probability of survival at six months estimated at 89.5% [95% CI 86.8-92.1] and among those surviving an estimated probability of remaining on treatment of 94% [95% CI 91.8-96.1]. [3]

A recent article in the New York Times, announcing: “Africans outdo Americans following AIDS therapy”, describes the Khayelitsha project as having “…extraordinary levels of compliance”. [4]