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Long-term Challenges for ARV Programmes on the African Continent: Experience From Southern Africa

Presenter: Eric Goemaere
Author(s): Eric Goemaere1, D. Coetzee2, A. Boulle2, G. Van Cutsem3, K. Hilderbrand3
Affiliation(s): 1Médecins sans frontières (MSF) South Africa, Head of Mission, Cape Town, South Africa, 2Department of Public Health and Family Medicine, University of Cape Town, 3MSF South Africa
Key issues: The first projects to routinely offer free ART in resource-constrained settings have now been in operation for 5 years. We describe trends and outcomes after 5 years of treatment provision in one such programme in Khayelitsha, South Africa, while drawing lessons from similar MSF experiences in the Southern African Region.
Meeting challenges:: Prospective cohort study of all treatment-naïve adults started on ART until the end of 2005 in Khayelitsha and observational studies in other programmes.

In an analysis of > 2000 adults started on ART by the end of 2005, 76% of patients remain in care at 48 months, of whom 84% remain on their first-line regimen. Median baseline CD4 at initiation rose from 46 in 2001 to 105 in 2005, and correspondingly, mortality by 6 months fell in parallel from 13% to 5% (two-thirds of losses occurred in first six months). The proportion of patients attaining viral loads < 400 copies/ml at 6 months has remained stable between annual cohorts at between 88% and 91%. Long-term drug toxicity, mainly due to D4t (16.7% cumulatively by 36 months on stavudine compared to 8.3% on zidovudine), has necessitated the introduction of specific monitoring tools and will require an alternative first-line regimen in the middle term. At 48 months, 17 % of patients are on second-line, while there is no patient-friendly, affordable second-line regimen available for the time being. While total consultations have multiplied by more than 7 in the first 48 months to comply with scale up targets, they will still need to be multiplied by another factor 4 to reach universal coverage targets by 2010: this has major impact on the quality of care (loss to follow-up has increased to 4% at 12 months for the most recent annual cohort) and needs for decentralisation/ simplification. This can only be realised while applying a nurse-based strategy in an international context of nurses emigration due to poaching by Western countries.

Conclusion (max 400 words): ARV treatment at a large-scale is feasible and can be successful, but universal coverage will only be attainable if: new drugs and diagnostic tools are available, urgent measures are taken to limit health staff emigration, programmes are further simplified and approaches standardised.

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