Several years into the global roll out of ART, the key lesson learned is that it is indeed possible to get life-saving care and treatment to hundreds of thousands of people living in very diverse resource-limited settings. There were several reports at the conference of projects that have demonstrated this.
For instance, since July 2004, the International Center for AIDS Care and Treatment Programs at Columbia University (ICAP) has built upon a network of projects, which initially offered services to prevent mother-to-child transmission (PMTCT) of HIV, to establish an enormous comprehensive HIV care programme with 155 sites in Ethiopia, Kenya, Mozambique, Nigeria, Rwanda, South Africa and Tanzania. According to Dr. Wafaa El-Sadr, by December 2006, these sites had enrolled a total of 171,259 HIV-infected patients, 71,482 of whom have been initiated on ART.
Most of the programme’s patients on ART remain on their first-line regimen and have had good immunological responses. Across the countries the programme serves, 4 to 6% of the ART recipients have died and 1-17% have been lost to follow-up (more on this below). Of the remaining patients on ART, nearly all the adults (98%) and children (93%) are still on their first-line regimens. The average increase in median CD4 cell counts after six and twelve months of ART was 116 and 149 cells/mm3, respectively.
Likewise, a poster by Richard Marlink and colleagues described the phenomenally rapid scale-up of Project HEART (Help-Expand-ART), which was initiated in March 2004 by the Elizabeth Glaser Paediatric AIDS Foundation with funding from PEPFAR/CDC and private donors. In just 31 months, this programme enrolled over 167,000 adults and 87,000 children into care at sites in Cote d’Ivoire, South Africa, Tanzania, Zambia and recently Mozambique. Again, treatment outcomes in the programme are comparable to those in developed settings. The poster’s authors concluded “care and treatment was possible in a variety of settings, including areas of conflict, remote settings and very poor public sites.”
Many of these programmes might not be possible were it not for the example of one of the earliest and most catalytic ART programmes in the world, the Khayelitsha township project in the Western Cape of South Africa. Dr. Gilles Van Cutsem of Médecins Sans Frontières presented an analysis of the outcomes and emerging challenges at the project’s three clinics. Since it was one of the very first to offer ART in a developing country (beginning in 2001), the Khayelitsha project is now one of the first to be able to report outcomes for patients after four and five years of treatment.
Dr. Cutsem reported on 3373 patients enrolled between 2001 and 2005 with follow-up until September 2006. Although only a relatively small number of people entered the programme in 2001, of those to reach five years of follow-up, 70% were still alive and in care (about 16.9%, (95% confidence interval (CI) 13.6-21.0) are known to have died). Most (79%) of the patients on treatment at five years are still on their first line regimen.
Responses on treatment for the programme as a whole (and thus including those on first-line and second line regimens) have been exceptional. The mean increase in CD4 cell count from baseline after four and five years on ART was 429 (95% CI 388-469) and 440 (95% CI 341-541) cells/mm3 respectively. The programme is also unusual in resource limited settings in that it has been able to document viral load outcomes in its participants, with the proportion of patients [on treatment] with viral loads <400 copies per ml at years 1, 2, 3, 4 and 5 at 88.4%, 85.8%, 88.5, 79.1% and 82.1% respectively.
There were also oral reports from the national ART programme in Cameroon, Botswana’s treatment programme (the first national public health programme to offer free ART), and Uganda (where a variety of government clinics and other projects provide treatment). However, now that the rollout has been demonstrated as quite possible, the focus has shifted to the challenges, some of which have only emerged as programmes begin to reach the limits of their infrastructural capacity, to providing ongoing high quality care.