A recent article in the journal The Lancet reports that in poor countries, mortality and orphanhood associated with HIV can be reduced through a home-based antiretroviral treatment (ART) program. Dr Jonathan Mermin, Centers for Disease Control and Prevention, Nairobi, Kenya, and colleagues also recommend that the ART program be implemented throughout the rest of the world.
Currently, the most effective way to clinically treat patients with HIV and reduce mortality is ART. Ninety percent of HIV-infected people live in developing countries, and 63% live in Africa. ART is becoming more available to these people, but it is still not reaching many of the people in Africa who need it. Barriers such as high medication costs, few trained health-care providers, clinics that lack equipment, and long distances between people’s homes and health-care centers have made it difficult for people to receive treatment. In order for ART programs to be effective, patients need to adhere to medication, be monitored for drug toxicity, and continue to receive diagnosis and treatment of infections. These requirements could be best met in Africa with limited use of doctors and transportation, but instead the programs use lay workers.
In 2001, researchers enrolled 466 HIV-infected adults and 1481 HIV-uninfected household members in Uganda in a study. Daily co-trimoxazole prophylaxis (an antibiotic) was provided to HIV patients after five months. From May 2003 to December 2005, 138 infected eligible adults and 907 new HIV-infected participants and their 3,120 HIV-negative household members began participating in an ART study that provided therapy with stavudine, lamivudine, and nevirapine. Lay providers visited households every week and patients did not schedule any clinic visits after they enrolled in the study.
Findings are summarized below:
- 233 (17%) of 1373 people with HIV and 40 (1%) of 4601 HIV-uninfected people died.
- The death rate in HIV-infected participants who had ART and co-trimoxazole was 55% lower than with co-trimoxazole alone during the first 16 weeks; 92% lower after 16 weeks
- There was a 95% reduction in mortality in HIV-infected participants who had ART and co-trimoxazole compared to those who had no intervention
- An 81% reduction in mortality of uninfected children younger than 10 years old was associated with participants who received ART and co-trimoxazole compared to no intervention
- Orphanhood was reduced by about 93% for children of treated adults
“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…our findings support the efforts to bring ART to people with HIV throughout the world, irrespective of geographic or socioeconomic background,” conclude the authors.
Dr Eline Korenromp (Global Fund to Fight Aids, Tuberculosis and Malaria, Geneva, Switzerland, and University Medical Center, Rotterdam, Netherlands) and Dr Jane Kengeya Kayondo (UNICEF/UNDP/World Bank/WHO Special Program for Training in Tropical Diseases) write in an accompanying commentary: “The studies embedded in Mermin and colleagues’ programme show how operational research can successfully be done during scale-up. We should hope that more and more prevention and treatment programmes will use opportunities for optimising resource allocations and service deliveries through learning by doing.”
Mortality in HIV-infected Ugandan adults receiving antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study
Jonathan Mermin MD, Willy Were MB, John Paul Ekwaru MSc, David Moore MD, Robert Downing PhD, Prosper Behumbiize, John R Lule MB, Alex Coutinho MB, Jordan Tappero MD, and Rebecca Bunnell ScD
The Lancet (2008). 371:752-759
doi:10.1016/S0140-6736(08)60345-1
Written by: Peter M Crosta