Outcomes after two years of providing antiretrovirals in Khayelitsha, South Africa

Two year patient outcome from Medicins Sans Frontiers’ (MSF) best-known antiretroviral programme in Khayelitsha, South Africa was reported in the April edition of AIDS.

This analysis included all adults started on antiretroviral therapy from May 2001 to December 2002 (n=287). The median follow up time was 14.9 months for those surviving, and 13.9 overall.

In this cohort, 70% were women and patients had advanced disease – the median CD4 at base line was 43 cells/mm3 (IQR 13-94 cells/mm3) and 52% of patients had an AIDS diagnosis.

The majority of patients received NNRTI containing regimens: 60% began treatment with zidovudine, lamivudine and efavirenz and 38% with zidovudine, lamivudine and nevirapine.

The investigators reported HIV RNA viral load <400 copies/mL in 88.1, 89.2, 75.00 and 69.7% of patients at 3, 6, 12, 18 and 24 months respectively.

Survival at 24 months was estimated at 86.35% (95%CI, 81.7-89.8%). Stratified by CD4 count at initiation of treatment, estimates of survival were: 81.8% (95%CI, 74.7-87.0%) and 91.4% (95%CI, 84.9-95.1%) for those starting with CD4 <50 and >50 cells/mm3 respectively. Of this group 155 (55%) patients initiated treatment with a baseline CD4 count of <50 cells/mm3.

At 24 months on treatment the median increase in CD4 count was 288 cells/mm3 (95%CI, 181-470).

Regimen changes due to adverse events attributed to a single agent were highest in those receiving nevirapine with 8.8% (product limit estimate) of patients changing to efavirenz within 24 months. Only 4.7% switched from zidovudine to stavudine, none from lamivudine and two patients were unable to tolerate efavirenz side effects. Overall by 24 months 8.4% (95%CI, 5.6-12.5%) had any regimen change due to intolerance.

Some regimen changes also occurred due to changes in circumstances: 10 patients switched nevirapine to efavirenz due to development of tuberculosis (nevirapine is contraindicated for co-administration with rifampicin) and three patients from efavirenz to nevirapine due to pregnancy or planning pregnancy. The investigators reported a cumulative probability of regimen change due to adverse events or contraindications of 15.1% (95%CI, 10.7-21.1%) of all patients receiving first line therapy within 24 months. Additionally 12 patients changed their regimen due to treatment failure by the end of July 2003.

The authors write: The results of this programme are comparable with data from observational settings in both developed and developing countries…These findings provide encouragement to those seeking to provide similar services in poor communities where HIV mortality and morbidity are high.”

Coetzee D, Hildebrand K, Boulle A et al Outcomes after two years of providing antiretroviral treatment in Khayelitsha, South Africa. AIDS: Volume 18(6) 9 April 2004 pp 887-895.