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Rapid Scale-up of Antiretroviral Services in Zambia: 1-year Clinical and Immunologic Outcomes
Moses Sinkala*1, J Levy2, I Zulu3, A Mwango1, E Stringer2, B Chi2, S Reid2, T Ellerbrock4, M Bulterys5, and J Stringer2
1Ministry of Hlth, Lusaka, Zambia; 2Univ of Alabama at Birmingham, Ctr for Infectious Disease Res, Lusaka, Zambia; 3Univ of Zambia Sch of Med; 4CDC, Atlanta, GA, US; and 5CDC, Lusaka, Zambia
Background: Massive scale-up
of HIV care and treatment services is currently underway in a number of
developing countries. Whether these efforts will translate into favorable
long-term outcomes is not fully known.
Methods: We report on
programmatic outcomes from 18 public and private clinical sites across 3
provinces of Zambia.
Clinical care has been standardized according to national guidelines.
Initiation of ART is dependent upon World Health Organization (WHO) clinical
staging and CD4 cell count. First-line drug regimens are zidovudine
(ZDV) or stavudine (d4T), plus lamivudine
(3TC), plus nevirapine (NVP) or efavirenz
(EFV). Individual-level outcomes data are collected through a computerized
record system and standardized chart review.
Results: From April 2004 to
August 2005, we enrolled 18,075 adults into a government HIV care and treatment
program, and started 11,074 (61%) on ART. Of those starting ART, 6806 (61%) were
women. Among those commencing ART, mean CD4 was 131 (IQR 52 to182), 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
and 53% of deaths occurred within 60 days of enrollment. In a multivariable Cox
regression, restricted to those on ART, risk of death was strongly associated
with entry CD4+ count £50 (adjusted hazard ratio [AHR] = 2.1, 95%CI 1.8 to 2.4),
WHO stage III or IV (AHR = 1.9, 95%CI 1.5 to 2.4), body mass index <16 (AHR =
2.2, 95%CI 1.8 to 2.5), hemoglobin <8 (AHR = 2.6, 95%CI 2.2 to 3.1), and
male gender (AHR = 1.4, 95%CI 1.2 to 1.6). At least 6 months of follow-up was
given 11,854 individuals to allow assessment of CD4 response. Those starting
ART (n = 8284) had a greater mean
increase in CD4 at 6 months (+61 vs +5 cells/mL; p <0.0001) and at 12 months (+85 vs –23 cells/mL; p <0.0001)
than those not on ART.
Conclusions: Rapid initiation
of ART in a programmatic setting led to favorable clinical outcomes at 6 and 12
months in Zambia.
Advanced HIV disease was a very strong predictor of mortality in this
population, suggesting that every effort should be made to identify and treat infected
patients earlier in their disease course.
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