Secure antiretroviral therapy delivery in a resource-limited setting: streamlined to minimize drug resistance and expense.
BACKGROUND
We report the design and analysis of a streamlined approach to the delivery of antiretroviral therapy (ART) that minimized risk for emergence of ART drug resistance (ART-DR) in a resource-limited setting.


METHODS
The algorithm of care for persons with HIV comprised generic, fixed-dose, twice-daily stavudine, lamivudine and nevirapine (GPO-VIR), scheduled and unannounced pill counts and measurement of viral load at months 6 and 18 after initiation of ART. We evaluated adherence as measured by pill counts, HIV suppression and programmatic costs.


RESULTS
Over a 4-year period, 214 of 330 patients (64.8%) were enrolled; baseline median CD4 count was 84 cells/microL. At month 1, nine patients (4.2%) discontinued GPO-VIR because of skin rash. At month 6, 199 patients (93%) achieved viral load < or =400 HIV-1 RNA copies/mL, with current alcohol use the sole predictor of treatment failure [adjusted Relative Risk (aRR)=1.67; 95% confidence interval=1.05-2.48; P<0.001]. Most patients (97%) with HIV suppression at month 6 had viral loads < or =50 copies/mL at month 18; all had > or =75% visit compliance and 192 (98%) had > or =75% adherence measured by pill counts. The estimated annual costs were $111.92 per patient for the pill counts, home visits and viral load measurement.


CONCLUSIONS
Secure ART delivery, while minimizing risk for non-adherence and ART-DR, is clinically and economically feasible in this resource-limited setting.
Kitkungvan
D
D
Department of Internal Medicine, Thammasat University Hospital, Patumthani, Thailand.
Apisarnthanarak
A
A
Laowansiri
P
P
Mundy
L M
LM
D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count / Q000191:economics; D003906:Developing Countries; D016527:Drug Costs; D024882:Drug Resistance, Viral; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000191:economics* / Q000276:immunology; D006801:Humans; D019259:Lamivudine / Q000627:therapeutic use*; D008297:Male; D008875:Middle Aged; D019829:Nevirapine / Q000627:therapeutic use*; D011446:Prospective Studies; D012307:Risk Factors; D018119:Stavudine / Q000627:therapeutic use*; D013785:Thailand; D017211:Treatment Failure; D019562:Viral Load / Q000191:economics; D055815:Young Adult
D044966:Anti-Retroviral Agents; C516355:stavudine, lamivudine, nevirapine drug combination; D019259:Lamivudine; D019829:Nevirapine; D018119:Stavudine