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Monitoring of ART Rationing Procedures at a Single Site in Phnom Penh, Cambodia
Chel Sarim*1, S Huffam1, J Elliott1, C Hun1, P Sophea1, V Saphonn1, J Kaldor2, D Cooper2, and V Mean Chhi1
1Natl Ctr for HIV/AIDS, Dermatology and STI, Ministry of Hlth Cambodia, Phnom Penh and 2Natl Ctr in HIV Epidemiology and Clin Res, Univ of New South Wales, Sydney, Australia
Background: In resource-limited settings where demand
for ART exceeds supply, rationing is achieved by referral and selection
procedures. In Cambodia
the majority of HIV clinics (16 of 20, 80%) use a committee to select people for
ART based on clinical, immunological, and social criteria. We undertook an
analysis of equity of access at a public clinic in Phnom Penh where selection was undertaken on
the basis of clinical and immunological criteria alone, without the involvement
of a committee.
Methods: In a prospective study of patients enrolling
at an ambulatory HIV clinic, we assessed whether enrollment was related to
gender, and whether commencement on ART was related to gender, education level,
or residential status (Phnom Penh
or province). All patients were referred from a single free Voluntary
Confidential Counseling and Testing (VCCT) site. Those found to be eligible on
clinical (World Health Organization Stage IV) or immunological (CD4 <200
cells/mm3) criteria commenced ART after attending at least 3
counseling sessions, subject to agreement between the counselor, treating
doctor, and senior clinician.
Results: For the first 6 months of 2005, the ratio of
women who enrolled at the clinic to women testing positive for HIV at the VCCT was
lower than the ratio for men, 101 of 517, 0.20 vs 121 of 449, 0.27; p = 0.01. Of the 479 adults enrolled in
the clinic to end September 2005, 309 (64.5%) were found to be eligible for ART
and 214 (69.2% of those eligible) started. Median time from first visit to
commencement of ART was 47 days (range 21 to 161). Among eligible patients, there
was no difference in the proportion starting treatment according to gender (p = 0.13) or residential status (p = 0.41), but adults who did not have
any high school education were less likely to start ART than those who did, 90
of 150 vs 124 of 159; p = 0.01. There
was no significant association between these categories and the median time from
enrollment to starting ART.
Conclusions: Rationing of ART through referral from a
single source, and selection using clinical/immunological criteria without a
selection committee resulted in men having a higher likelihood of enrollment at
the clinic than women, and those with better education were more likely to
start treatment. Transparent monitoring systems are feasible and are necessary
to ensure referral and selection procedures maximize equity, efficiency, and
treatment outcomes.
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