Wools-Kaloustian K, Kimaiyo S, Musick B, et al. The impact of the President's Emergency Plan for AIDS Relief on expansion of HIV care services for adult patients in western Kenya. AIDS 2009;23:195-201.
To assess the impact of The President's Emergency Plan for AIDS Relief (PEPFAR) on the treatment services of an HIV care program in western Kenya
Cohort study of non-pregnant adults enrolled into the Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) system. Data were extracted from the AMPATH electronic medical record system and compared across three periods representing increased funding for and availability of combination antiretroviral therapy (ART).
Western Kenya AMPATH clinics operated by the Kenyan Ministry of Health, November 2001 to July 2006
Adult patients were eligible for inclusion if they were enrolled at any AMPATH clinic between November 2001 and May 2006. Pregnant women were excluded because their initiation and duration of ART differs from the standard protocol. As of May 2006, 26,539 non-pregnant adults had been enrolled in AMPATH. The median age at enrollment was approximately 36 years and remained unchanged across all periods (P>0.1).
AMPATH is a joint initiative between Moi University and Moi Teaching and Referral Hospital in Eldoret, Kenya, and the Indiana University School of Medicine. The goal of AMPATH was to establish an HIV care system to serve the needs of both urban and rural patients, create a partnership to assess and overcome barriers to care, and improve outcomes of cART in a resource-poor setting. The ART regimen used throughout the study period consisted of stavudine, lamivudine, and nevirapine. AMPATH has experienced three periods as defined by funding for and availability of ART: Period 1 began November 2001; cART was funded through patient self-pay and private donations; approximately $650,000 total funding. Period 2 began June 2003; wide availability of generic combination ART, lowered monthly per patient cart costs from $40 to $23, private donations; >$1,000,000 total funding. Period 3 began March 2004; $6.5 million in PEPFAR funding for HIV care in addition to ART at no cost to the program.
Number of AMPATH clinics; number of patients enrolled in AMPATH clinics; patient demographic, immunologic, and clinical characteristics
Number of AMPATH clinics: Two clinics (one urban and one rural) were established during Period 1; two additional rural clinics were added in Period 2; 13 clinics (three urban or semi-urban and 10 rural) were added during Period 3.
Number of patients enrolled in AMPATH clinics: During Period 1, AMPATH enrolled 64.2 new patients per month; during Period 2, 118 new patients per month; and during Period 3, 817 new patients per month.
Patient demographics, immunologic, and clinical characteristics: 6.7% of patients had WHO stage 4 disease during Period 3 compared with 13.8% in Period 1 (P<0.001) and 14.8% during Period 2 (P<0.001). Median CD4 cell count within 6 months of enrollment for Period 3 was 172 cells/µL, compared to 146 cells/µL during period 1 (P<0.001) and 119 cells/µL during Period 2 (P<0.001). The time from enrollment to initiation of ART decreased significantly from a median of 63.7 weeks during Period 1 to 26.3 weeks during Period 2 and 12.0 weeks in Period 3 (P<0.001). Loss to follow-up was 15.9% at 6 months and 20.2% at 12 months for patients enrolled in Period 1. For patients enrolled during Period 2, loss to follow-up increased significantly to 22.0% and 27.9% (P<0.001), and for patients enrolled during Period 3, was 18.0% and 24.3%, respectively (P=0.004 when compared to Period 2).
The authors conclude that PEPFAR funding has allowed AMPATH to significantly increase the number of individuals receiving HIV care and provided the ability to expand services allowing for identification of patients earlier in their disease process.
There are no quality rating scales for studies of this type. Because data were collected as part of routine clinical care, the findings are dependent on the limitations of the clinic environment. With no randomly assigned control group, the findings cannot be definitively attributed to PEPFAR funding.
No large-scale ART program has assessed the impact of PEPFAR on program expansion and effectiveness. The receipt of PEPFAR funds allowed AMPATH to triple its number of treatment sites and accelerated the enrollment of HIV-infected patients by a factor of six. High loss to follow-up during all periods is of great concern and is reflective of the reality for the majority of HIV care programs in sub-Saharan Africa.(1,2,3) In a recent systematic review of loss to follow-up in sub-Saharan Africa ART programs, retention was found to be significantly better in cohorts that did not require payment for services.(3) Within the AMPATH program, retention was highest during Period 1, when the cohort was small and costs were covered for most patients. Lower retention in Period 3 could be the result of a less selective patient population as the program matured, increasing patient panels leading to less provider time to reinforce adherence, and an increasing number of alternative ART care sites.
PEPFAR funds have significantly increased the ability of individuals residing in western Kenya to access HIV care. It is anticipated that this access will, over time, lead to earlier HIV diagnosis and initiation of treatment, thus allowing more prolonged maintenance of health and economic wellbeing. Despite this improvement in access, loss to follow-up continues to be a significant issue for the majority of ART programs. Further strides in ART roll-out only can be maintained with the continued financial commitment by international donors.
- Toure S, Kouadio B, Seyler C, et al. The Aconda Study Group. Rapid scaling-up of antiretroviral therapy in 10,000 adults in Cote d'Ivoire: 2-year outcomes and determinants. AIDS 2008;22:873-82.
- Stringer JS, Zulu I, Levy J, et al. Rapid scale-up of antiretroviral therapy at primary care sites in Zambia: feasibility and early outcomes. JAMA 2006;296;782-93.
- Rosen S, Fox M, Gill C, Patient retention in antiretroviral therapy programs in sub-Saharan Africa: a systematic review. PLoS Med 2007;4(10):e298.