Outcomes of Antiretroviral Treatment Programs in Rural Southern Africa

The World Health Organization (WHO) estimates that more than 5 million HIV-1–infected people were receiving antiretroviral therapy (ART) in low-income and middle-income countries by the end of 2009. However, high mortality and loss of patients to follow-up in the context of the rapid scale-up of ART and weak health systems challenge clinical and programmatic outcomes in low-income settings in Africa. In recent years, an increasing body of evidence, including 2 systematic reviews, has shown low retention in care of patients starting ART in sub-Saharan Africa. Early losses after the initiation of ART have been recognized as important barriers to the success of ART programs in resource-constrained settings.

According to a recent report based on aggregate data from national programs, retention in care in countries in sub-Saharan Africa is estimated to be as low as 75.2% at 12 months, possibly due to high early mortality.

Data on short-term and long-term clinical and programmatic outcomes in rural sub-Saharan Africa, especially in settings with limited diagnostic possibilities, access to viral load testing and second-line ART, are scarce. Due to many structural factors influencing the scale-up of ART, the distribution of services may be inequitable between rural and urban African settings. For instance, the impact of the chronic shortage of health care workers has been most devastating in rural settings.

Mozambique, Zimbabwe, and Lesotho are 3 countries with a high prevalence of HIV infection where ART delivery has been scaled up in the last few years. Despite the substantial increase in patients starting ART, only 30%, 34%, and 48% of the HIV-infected population in need of treatment in Mozambique, Zimbabwe, and Lesotho, respectively, were estimated to have access to ART by 2009. In this context, SolidarMed, a Swiss nongovernmental organization, established the SolidarMed AntiRetroviral Treatment (SMART) program in 2005, with a focus on supporting the delivery of ART and health care in rural settings in sub-Saharan Africa. We examined the importance of no follow-up after initiation of ART and mortality and loss to follow-up (LTFU) over 3 years of ART in the SMART programs in Zimbabwe, Mozambique, as well as Lesotho…

In conclusion, our study illustrates some of the challenges rural ART programs face in sub-Saharan Africa. In particular, our results document the difficulties in retaining patients in care after they initiate ART and must raise concerns about poor long term clinical outcomes in settings with weak health systems and limited access to viral load monitoring and second-line ART regimens. Approaches to improve retention in care in such settings have been described recently, including reduction of the frequency of visits in patients who are stable, down referral of ART, and the involvement of peer support groups. Such interventions need to be tailored to local contexts and implemented alongside
health systems strengthening initiatives. (JAIDS Journal of Acquired Immune Deficiency Syndromes, 1 February 2012)

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