Home-based ARV programme would save lives

Rolling out a home-based antiretroviral treatment (ART) programme run by  community workers  could substantially reduce adult deaths and orphanhood in poor countries.

This is the conclusion of Jonathan Mermin and colleagues, authors of an article in this week’€™s edition of The Lancet journal.

ART is increasingly available in Africa, but doctors and clinical services are few, with most countries, including South Africa, only allowing pharmacists and doctors to dispense and prescribe the medication.

Researchers from the Centers for Disease Control and Prevention in Nairobi, Kenya began their analysis with a 2001 study of 466 HIV-infected adults and 1481 HIV-uninfected household members in Uganda, and after 5-months provided daily co-trimoxazole prophylaxis to HIV patients.

Between 2003 and 2005 138 HIV-infected adults who were eligible, and 907 new HIV-infected participants and their 3120 uninfected household members were then enrolled in an ART study (using mainly stavudine, lamivudine, and nevirapine).

Households were visited every week by lay providers, and no clinic visits were scheduled after enrolment.

The researchers found that 233 (17%) of 1373 people with HIV and 40 (1%) of 4601 HIV-uninfected people died. During the first 16 weeks of ART and co-trimoxazole, mortality in HIV-infected participants was 55% lower than that during co-trimoxazole alone; and after 16 weeks, was reduced by 92%.

Compared with no intervention, ART and co-trimoxazole were associated with a 95% reduction in mortality in HIV-infected participants; an 81% reduction in mortality in their uninfected children younger than 10 years; and a 93% estimated reduction in orphanhood.

The authors concluded: ‘€œA home-based ART and co-trimoxazole programme was associated with a greater than 90% reduction in mortality in adults with HIV living in rural Uganda. These results were achieved even though no routine clinic visits were scheduled after initial enrolment, and home visits were provided by trained lay providers. Provision of ART to adults was also associated with a large reduction in mortality in their HIV-negative children, and with substantial reductions in the rate of orphanhood… our findings support the efforts to bring ART to people with HIV throughout the world, irrespective of geographic or socioeconomic background.’€

ART is widely accepted as the most effective clinical intervention for reduction of mortality in people with HIV. It is increasingly available in developing countries where 90% of HIV-infected people live’€”including 63% in Africa.

However despite substantial efforts ART treatment is still not reaching many people who need it. Problems include high costs of medication, inadequate numbers of trained health-care providers, poorly equipped clinics, and long distances between people’€™s homes and health centres.

Effective ART programmes require high adherence to medication, monitoring for potential drug toxicity, and continuing diagnosis and treatment of opportunistic infections. Ideally, ART programmes in Africa could provide this with limited use of doctors and transport, and instead use lay workers, the researchers said.

‘€œThe studies embedded in Mermin and colleagues’€™ programme show how operational research can successfully be done during scale-up. We should hope that more and more prevention and treatment programmes will use opportunities for optimising resource allocations and service deliveries through learning by doing,’€ said Dr Eline Korenromp of the Global Fund to Fight Aids, Tuberculosis and Malaria.  ‘€“ Health-e News.

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