171 Preliminary Outcomes of Directly-observed Treatment of Advanced HIV Disease with ARVs (DOT-HAART) in Rural Haiti P. Farmer*1, F. Leandre2, S. Koenig1, P. Nevil2, J. Mukherjee1, J. Ferrer2, B. Walker1, C. Orelus2, M. Smith-Fawzi1 1Harvard Med Sch, Boston, MA and 2Zanmi Lasante, Cange, Haiti
Background: HIV, the leading infectious cause of adult deaths in the world today, is concentrated in extremely resource-poor settings. Beginning in late 1998, we introduced ARVs to the formulary of a clinic in rural Haiti, using serology and clinical criteria to determine access to DOT-HAART: directly observed therapy with antiretroviral therapy. DOT was performed by community-health workers (CHWs).
Methods: Retrospective chart review; serial assessments of key clinical and laboratory parameters; focus groups; and ethnographic study. Outcomes were compared between 3 groups: the first 100 patients (pts) who received > 1 month of DOT-HAART from a CHW; 100 pts diagnosed with HIV infection during the same period and from within the catchment area who received regular care, but deemed less sick than those who received ARVs; 100 pts diagnosed with HIV infection during the same period but living outside the area served by CHWs. All medical care was provided free of charge.
Results: Regardless of endpoint chosen (mortality, weight trend, number of OIs or hospitalizations during study period, ability to perform activities of daily living, or stigma) pts who received DOT-HAART had better outcomes when compared to the other 2 groups. There have been 0 deaths among the first 100 DOT-HAART pts. Among pts who did not receive ARVs but rather aggressive treatment of OIs and isoniazid prophylaxis and access to CHWs, outcomes were better than among pts who did not live within the catchment area, but mortality was high (during the study period, > 10% and 20%, respectively) in both groups; hospitalizations and complications were more frequent than among DOT-HAART pts.
Conclusions: DOT-HAART relying on CHWs is feasible and effective in resource-poor settings. Programs providing only treatment of OIs can hope to reduce morbidity and mortality, but are less effective. Stigma was lessened by the introduction of ARVs; staff morale was improved.