Rapid scale-up of treatment in Zambia delivered at primary health level
Polly Clayden, HIV i-Base
Scale up of HIV care and treatment services is currently underway in a number of developing countries. In an oral presentation Moses Sinkala from the Zambian Ministry of Health reported on programmatic outcomes from 18 public and private clinical sites across the Lusaka area of Zambia.
Lusaka has a population of 1.6 million and an HIV prevalence rate of 22%. There are currently an estimated 260,000 HIV positive adults and children of whom 56,000 need antiretrovirals and another 28,000 will become eligible each year.
In this programme, clinical care is standardised according to national guidelines. Initiation of ART is according to World Health Organisation (WHO) clinical staging and CD4 cell count. First-line drug regimens are also according to WHO recommendations: AZT or d4T + 3TC +nevirapine (NVP) or efavirenz (EFV). The majority of patients received NVP; only 8% received EFV. These were patients in the intensive phase of TB treatment.
Between May 2004 and December 2005, over 36,500 patients were enrolled into care and 22,121 started on HAART.
Of those patients starting ART, the median age was 35 years (IQR 30-42 years); 10,691 (61%) were women and 2,583 had had TB in the past year. 3,920 (24%) patients had CD4 counts >/= 200 cells/mm3, 8937 (55%) had CD4 counts >/= 50 cells/mm3 and 3,476 (21%) had CD4 counts of <50 cells/mm3.
Analysis of patients enrolled and starting ART to August 2005 found the mean CD4 was 131 cells/mm3 (IQR: 52 to 182 cells/mm3), mean body mass index was 21.3 (IQR 17.9 to 22.4), and 8009 patients (73%) were WHO stage III or IV. Over 81,248 patient-months, 1269 patients died (crude death rate 0.016 deaths/patient-month); 43% of deaths occurred in patients with entry CD4 <50 cells/mm3 and 53% of deaths occurred within 60 days of enrolment into the programme.
In a multivariate analysis of factors associated with survival, hazard ratios (HR) for risk of death were: WHO stage III, HR 2.0 (95% CI: 1.4-2.7) and stage IV, HR 3.3 (95% CI: 2.3-4.9); CD4 (ref 200 cells/mm3) 50 – <200 cells/mm3, HR 1.5 (95%CI 1.1-2.0) and <50 cells/mm3, HR 2.1 (95% CI: 1.5-3.0); TB, HR 1.0 (95% CI: 0.7-1.3; BMI <16 2.3 (95% CI: 1.8-3.1); HGB, HR <8.0; male sex, HR 1.1 (95% CI: 0.9-1.4) and non adherence, 90th percentile, HR 3.1 (95% CI: 2.1-4.5)
An analysis of 8284 patients receiving ART found a greater mean increase in CD4 at 6 months (+61 vs. +5 cells/mm3; p <0.0001) and at 12 months (+85 vs. 23 cells/mm3; p <0.0001) than those not receiving ART.
Dr Sinkala concluded: Rapid deployment of ART services at the primary level is feasible and leads to favourable patient outcomes. Mortality among patients with advanced disease is high, indicating need for early diagnosis and treatment.
This rapid rollout in primary care sites is clearly impressive. Questions from the floor concerning loss to follow up and the mortality rate between receiving an HIV diagnosis and taking a CD4 test in order to initiate therapy were not really answered.
It would have been useful to hear more discussion around these questions.
Sinkala M, J Levy J, Zulu I et al. Rapid scale-up of antiretroviral services in Zambia: 1-year clinical and immunologic outcomes. 13th CROI, Denver, 2006. Abstract 64.