title: Antiretroviral therapy in a community clinic--early lessons from a pilot project.
abstract: OBJECTIVE
  To report on operational and clinical problems encountered during the first 6 months of a community-based antiretroviral therapy (ART) programme.
  
  
  METHODS
  ART was implemented in a primary care setting utilising an easily replicable service-delivery model based on a medical officer and nurse. Therapeutic counsellors, themselves HIV-infected, provided counselling and adherence support. Drug and monitoring costs were charitably funded and provincial health authorities supplied the medical infrastructure. The HIV Research Unit, University of Cape Town, supplied training and additional clinical support. Local HIV primary care clinics provided patient referrals. Standardised ART regimens were used with strict entry criteria (AIDS or CD4 count < 200 cells/microliter).
  
  
  RESULTS
  Demand for the service was high. Referred patients had advanced disease (AIDS 57%, median CD4 count 96/microliter) and high pre-treatment mortality (83/100 person-years). Mycobacterial disease was a major contributor to this mortality (40%). Scheduled clinic visit hours were six times higher during recruitment than maintenance. Attributable costs were: drugs 61%, staff 27%, viral load and CD4 cell counts 10% and safety monitoring 2%. Viral load after 16 weeks of therapy was < 400 copies/ml in the first 16 patients.
  
  
  CONCLUSIONS
  ART can be successfully implemented within a primary care setting. Drug purchases and staff salaries drive programme costing. The service model is capable of managing 250-300 patients on chronic ART, but staffing needs to be increased during recruitment. Attention must be given to the diagnosis of tuberculosis during screening and early ART. Incorporating therapeutic counsellors into the programme increased community involvement and utilised a valuable and previously untapped resource.
authors.affiliation: HIV Research Unit, University of Cape Town, Provincial Administration of the Western Cape.
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.forename: Catherine
authors.initials: C
authors.lastname: Orrell
authors.forename: Larissa
authors.initials: L
authors.lastname: Reader
authors.forename: Kwezi
authors.initials: K
authors.lastname: Matoti
authors.forename: Karen
authors.initials: K
authors.lastname: Cohen
authors.forename: Rob
authors.initials: R
authors.lastname: Martell
authors.forename: Fareed
authors.initials: F
authors.lastname: Abdullah
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
mesh_terms: D000163:Acquired Immunodeficiency Syndrome / Q000188:drug therapy; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D003153:Community Health Services / Q000191:economics / Q000379:methods*; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D010865:Pilot Projects; D013019:South Africa