title: Uptake of WHO recommendations for first-line antiretroviral therapy in Kenya, Uganda, and Zambia.
abstract: BACKGROUND
  Antiretroviral therapy (ART) guidelines were significantly changed by the World Health Organization in 2010. It is largely unknown to what extent these guidelines were adopted into clinical practice.
  
  
  METHODS
  This was a retrospective observational analysis of first-line ART regimens in a sample of health facilities providing ART in Kenya, Uganda, and Zambia between 2007-2008 and 2011-2012. Data were analyzed for changes in regimen over time and assessed for key patient- and facility-level determinants of tenofovir (TDF) utilization in Kenya and Uganda using a mixed effects model.
  
  
  RESULTS
  Data were obtained from 29,507 patients from 146 facilities. The overall percentage of patients initiated on TDF-based therapy increased between 2007-2008 and 2011-2012 from 3% to 37% in Kenya, 2% to 34% in Uganda, and 64% to 87% in Zambia. A simultaneous decrease in stavudine (d4T) utilization was also noted, but its use was not eliminated, and there remained significant variation in facility prescribing patterns. For patients initiating ART in 2011-2012, we found increased odds of TDF use with more advanced disease at initiation in both Kenya (odds ratio [OR]: 2.78; 95% confidence interval [CI]: 1.73-4.48) and Uganda (OR: 2.15; 95% CI: 1.46-3.17). Having a CD4 test performed at initiation was also a significant predictor in Uganda (OR: 1.43; 95% CI: 1.16-1.76). No facility-level determinants of TDF utilization were seen in Kenya, but private facilities (OR: 2.86; 95% CI: 1.45-5.66) and those employing a doctor (OR: 2.86; 95% CI: 1.48-5.51) were more likely to initiate patients on TDF in Uganda.
  
  
  CONCLUSIONS
  d4T-based ART has largely been phased out over the study period. However, significant in-country and cross-country variation exists. Among the most recently initiated patients, those with more advanced disease at initiation were most likely to start TDF-based treatment. No facility-level determinants were consistent across countries to explain the observed facility-level variation.
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Herbert C
authors: HC
authors: Duber
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Emily
authors: E
authors: Dansereau
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Samuel H
authors: SH
authors: Masters
authors: Infectious Disease Research Collaboration, Makerere University, Kampala, Uganda.
authors: Jane
authors: J
authors: Achan
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Roy
authors: R
authors: Burstein
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Brendan
authors: B
authors: DeCenso
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Anne
authors: A
authors: Gasasira
authors: Infectious Disease Research Collaboration, Makerere University, Kampala, Uganda.
authors: Gloria
authors: G
authors: Ikilezi
authors: Action Africa Help-International, Nairobi, Kenya.
authors: Caroline
authors: C
authors: Kisia
authors: Department of Economics, University of Zambia, Lusaka, Zambia.
authors: Felix
authors: F
authors: Masiye
authors: Action Africa Help-International, Nairobi, Kenya.
authors: Pamela
authors: P
authors: Njuguna
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Thomas
authors: T
authors: Odeny
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Emelda
authors: E
authors: Okiro
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: D Allen
authors: DA
authors: Roberts
authors: Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, United States of America.
authors: Emmanuela
authors: E
authors: Gakidou
mesh_terms: D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods; D005260:Female; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007630:Kenya; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018119:Stavudine / Q000627:therapeutic use; D000068698:Tenofovir / Q000627:therapeutic use; D014454:Uganda; D014944:World Health Organization; D055815:Young Adult; D015024:Zambia
chemical_list: D019380:Anti-HIV Agents; D000068698:Tenofovir; D018119:Stavudine