Charalambous S, Grant AD, Day JH, Pemba L, Chaisson RE, Kruger P, Martin D, Wood R, Brink B, Churchyard GJ. Establishing a Workplace Antiretroviral Therapy Programme in South Africa. AIDS Care. 2007 Jan;19(1):34-41.
To set up a workplace antiretroviral therapy program at a large multinational company in South Africa.
This is not a study, but rather a description of the ART program rollout. In November 2002, the existing HIV prevention and care programs were expanded to include the provision of ART to medically eligible employees. This descriptive report is based on data from November 2002 to December 2004.
Occupational health centers, hospital clinics, primary care clinics, and general practitioner offices located in rural and urban areas in seven of the nine provinces in South Africa.
The multinational company has a workforce of 140,000 employees, with an estimated workforce HIV prevalence of 24% (33,400 employees). During November 2002 to December 2004, 2,456 patients who were employees of the multinational company began treatment.
There was no intervention, since this paper describes the establishment of an ART program, not a study. Aurum Institute for Health Research is an independent health systems and research public benefit organization that has previously designed and implemented HIV clinics in South Africa. To expand the existing HIV programs for employees, a consortium was established, consisting of Aurum, a clinical HIV consultancy, a pharmacy, and an HIV specialist laboratory. A clinical program was designed to guide healthcare workers in the implementation of ART. The clinical program consisted of standardized ART clinical guidelines, ART data collection forms, a data management system, a counseling guide, training materials, and patient education resources. Factors specific to the region, such as high rates of co-infection with TB, were included in the program. Counseling sessions were given to all patients offered treatment, and patients were scheduled for regular follow-up visits for 24 weeks after treatment initiation. Tight pharmaceutical control was achieved through computerized stock control, batch tracing, and named-patient dispensing. A courier service was used to distribute monthly supplies of medications to the appropriate sites. Data were collected on standardized forms and transported or faxed to the central Aurum offices, where the data were double-entered into a database and merged with laboratory and pharmacy electronic records. All healthcare staff underwent intensive training before working in the program. Lastly, at inception the sites were monitored through monthly sites visits, which later became visits every second month as the sites became more established. An HIV coordinating committee, with representatives from subsidiary companies, met every two months to evaluate the progress of the program and address any problems that arose.
Number of new workplace ART sites, number of employees receiving ART, and adherence.
Between November 2002 and December 2004, ART delivery was established at 70 workplaces with 200 to 12,000 employees each. The delivery ART sites included small occupational health clinics, general practitioner offices, primary care clinics, and hospital clinics. During this period, 70 doctors, 208 nurses, and 30 counselors participated in the training program. A total of 2,456 patients began ART by December 2004. Of the 2,204 patients who had received ART for at least three months, 1729 (78.4%) were alive and still on treatment, 129 (6.2%) had died, 48 (2.3%) were lost to follow-up, 298 (13.5%) had interrupted treatment, and 38 (1.7%) were switched to a second-line regimen. Of the patients advised to commence ART, 66 (2%) refused. Adherence (measured by patient self-report of missed tablets in past three days) was perfect (no tablets missed) in greater than 90% of patient visits.
Among the 1,784 individuals who commenced ART between November 2002 and September 2004, median CD4 count at the initiation of ART was 149 cells/µl and median viral load was 50,800 copies/µl. The median increase in CD4 count was 72 cells/µl at six weeks and 91 cells/µl at six months. Viral load results were available for 1,174 patients at six weeks, 81% of whom had at least a one log10 drop and 76% of whom had <400 copies/µl. At six months, results from 770 patients indicated that 71% had <400 copies/µl.
The authors conclude that this model for delivery of ART is feasible and successful in an industrial setting. The model may be generalizable to other employment health services in settings of high HIV prevalence, and as a model for implementing ART in other types of healthcare settings.
There is no formal rating system for descriptive papers. This paper has some limitations. The methods section does not clearly explain the process of expanding ART sites in the workforce. For example, the authors do not indicate how the ART sites were selected. It is not clear whether the ART sites were located at company facilities or off-site. Additionally, the authors do not explain in much detail how this program addressed one of their key issues of how to best maintain provision of medication and monitoring for migrants who returned home for long periods of leave. Further, there is no discussion regarding who conducts the monitoring visits, and how feedback from the healthcare staff and patients may be used to improve the program.
The overall good retention and immunologic and virologic responses achieved in this program are consistent with those seen in other African ART access initiatives,(1-4) and with those seen in Europe and the United States. A centralized model like this program worked well for a large company with sites throughout the country. However, the financial and logistical burden of such a centralized program, specific to a particular company, was not addressed in this article, therefore making it difficult to assess the feasibility and generalizability of the program in other settings. Additionally, the outcomes in this study reflect only a short time on ART. Sustainability of the program and the long-term outcomes of its patients must be established.
This model was successful in providing HIV-positive employees with ART at worksite health clinics. A similar model could be used for large multi-site workplaces in other countries, assuming the necessary financial resources and company commitment are available and sustainable. Details of program outcomes and the economic evaluation of this program will be published shortly. This information will be helpful in determining the cost-effectiveness of such programs and the feasibility of establishing such programs in other settings.
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- Weidle PJ, Malamba S, Mwebaze R, Sozi C, Rukundo G, Downing R, et al. Assessment of a pilot antiretroviral drug therapy programme in Uganda: patients' response, survival, and drug resistance. Lancet 2002 Jul 6;360(9326):34-40.
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