Rapid scale-up of a community-based HIV treatment service: programme performance over 3 consecutive years in Guguletu, South Africa
Bekker, L-Gail.; Myer, L.; Orrell, C.; Lawn, S.; Wood, R.
South African Medical Journal 96(4): 315-320
2006
ISSN/ISBN: 0256-9574 PMID: 16670804 Document Number: 599097
Background. Despite rapid expansion of antiretroviral therapy (ART) in sub-Saharan Africa there are few longitudinal data describing programme performance during rapid scale-up. Methods. We compared mortality, viral suppression and programme retention in 3 consecutive years of a public sector community-based ART clinic in a South African township. Data were collected prospectively from establishment of services in October 2002 to the censoring date in September 2005. Viral load and CD4 counts were monitored at 4-monthly intervals. Community-based counsellors provided adherence and programme support. Results. During the study period 1 139 ART-naive patients received ART (161, 280 and 698 in the 1st, 2nd and 3rd years respectively). The median CD4 cell counts were 84 cells/ micro l (interquartile range (IQR) 42-139), 89 cells/ micro l (IQR 490-149), and 110 cells/ micro l (IQR 55-172), and the proportions of patients with World Health Organization (WHO) clinical stages 3 and 4 were 90%, 79% and 76% in each sequential year respectively. The number of counsellors increased from 6 to 28 and the median number of clients allocated to each counsellor increased from 13 to 33. The overall loss to follow-up was 2.9%. At the date of censoring, the Kaplan-Meier estimates of the proportion of patients still on the programme were 82%, 86% and 91%, and the proportion who were virally suppressed (<400 copies/ml) were 100%, 92% and 98% for the 2002, 2003 and 2004 cohorts respectively. Conclusions. While further operational research is required into optimal models of care in different populations across sub-Saharan Africa, these results demonstrate that a single community-based public sector ART clinic can extend care to over 1 000 patients in an urban setting without compromising programme performance.