title: Adoption of new HIV treatment guidelines and drug substitutions within first-line as a measure of quality of care in rural Lesotho: health centers and hospitals compared.
abstract: OBJECTIVE
  In 2007, Lesotho launched new national antiretroviral treatment (ART) guidelines, prioritising tenofovir and zidovudine over stavudine as a backbone together with lamivudine. We compared the rate of adoption of these new guidelines and substitution of first-line drugs by health centers (HC) and hospitals in two catchment areas in rural Lesotho.
  
  
  METHODS
  Retrospective cohort analysis. Patients aged ≥16 years were stratified into a HC- and a hospital-group.
  
  
  METHODS
  Type of backbone at ART-initiation (i), substitutions within first line (ii) and type of backbone among patients retained by December 2010 (iii). A multiple logistic regression model including HC vs. hospital, patient characteristics (sex, age, WHO-stage, baseline CD4-count, concurrent pregnancy, concurrent tuberculosis treatment) and year of ART-start, was used.
  
  
  RESULTS
  Of 3936 adult patients initiated on ART between 2007 and 2010, 1971 started at hospitals and 1965 at HCs. Hospitals were more likely to follow the new guidelines as measured by prescription of backbones without stavudine (Odds-ratio 1.55; 95%CI: 1.32-1.81) and had a higher rate of drug substitutions while on first-line ART (2.39; 1.83-3.13). By December 2010, patients followed at health centres were more likely to still receive stavudine (2.28; 1.83-2.84).
  
  
  CONCLUSIONS
  Health centers took longer to adopt the new guidelines and substituted drugs less frequently. Decentralised ART-programmes need close support, supervision and mentoring to absorb new guidelines and to adhere to them.
authors: SolidarMed, Maseru, Lesotho  Seboche Hospital, Botha-Bothe, Lesotho  SolidarMed, Lucerne, Switzerland  Institute of Tropical Medicine, Antwerp, Belgium.
authors: Niklaus D
authors: ND
authors: Labhardt
authors: Motlalepula
authors: M
authors: Sello
authors: Thabo
authors: T
authors: Lejone
authors: Jochen
authors: J
authors: Ehmer
authors: Mohlaba
authors: M
authors: Mokhantso
authors: Lutgarde
authors: L
authors: Lynen
authors: Karolin
authors: K
authors: Pfeiffer
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D057915:Drug Substitution; D005260:Female; D019983:Guideline Adherence; D015658:HIV Infections / Q000188:drug therapy*; D006268:Health Facilities / Q000592:standards*; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007927:Lesotho; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011787:Quality of Health Care; D012189:Retrospective Studies; D012424:Rural Population; D055815:Young Adult
chemical_list: D019380:Anti-HIV Agents