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Open Access Research article

Improved antiretroviral treatment outcome in a rural African setting is associated with cART initiation at higher CD4 cell counts and better general health condition

Erik Mossdorf1245, Marcel Stoeckle45, Emmanuel G Mwaigomole12, Evarist Chiweka12, Patience L Kibatala1, Eveline Geubbels3, Honoraty Urassa2, Salim Abdulla3, Luigia Elzi5, Marcel Tanner4, Hansjakob Furrer6, Christoph Hatz4 and Manuel Battegay5*

Author Affiliations

1 St. Francis Designated District Hospital, Ifakara, United Republic of Tanzania

2 Ifakara Health Institute, Ifakara, United Republic of Tanzania

3 Ifakara Health Institute, Dar es Salaam, United Republic of Tanzania

4 Swiss Tropical and Public Health Institute, University Basel, Basel, Switzerland

5 Division of Infectious Diseases & Hospital Epidemiology, University Hospital Basel, Basel, Switzerland

6 Division of Infectious Diseases, University Hospital and University of Berne, Berne, Switzerland

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BMC Infectious Diseases 2011, 11:98  doi:10.1186/1471-2334-11-98

Published: 19 April 2011

Abstract

Background

Data on combination antiretroviral therapy (cART) in remote rural African regions is increasing.

Methods

We assessed prospectively initial cART in HIV-infected adults treated from 2005 to 2008 at St. Francis Designated District Hospital, Ifakara, Tanzania. Adherence was assisted by personal adherence supporters. We estimated risk factors of death or loss to follow-up by Cox regression during the first 12 months of cART.

Results

Overall, 1,463 individuals initiated cART, which was nevirapine-based in 84.6%. The median age was 40 years (IQR 34-47), 35.4% were males, 7.6% had proven tuberculosis. Median CD4 cell count was 131 cells/μl and 24.8% had WHO stage 4. Median CD4 cell count increased by 61 and 130 cells/μl after 6 and 12 months, respectively. 215 (14.7%) patients modified their treatment, mostly due to toxicity (56%), in particular polyneuropathy and anemia. Overall, 129 patients died (8.8%) and 189 (12.9%) were lost to follow-up. In a multivariate analysis, low CD4 cells at starting cART were associated with poorer survival and loss to follow-up (HR 1.77, 95% CI 1.15-2.75, p = 0.009; for CD4 <50 compared to >100 cells/μl). Higher weight was strongly associated with better survival (HR 0.63, 95% CI 0.51-0.76, p < 0.001 per 10 kg increase).

Conclusions

cART initiation at higher CD4 cell counts and better general health condition reduces HIV related mortality in a rural African setting. Efforts must be made to promote earlier HIV diagnosis to start cART timely. More research is needed to evaluate effective strategies to follow cART at a peripheral level with limited technical possibilities.

Keywords:
HIV-1; antiretroviral therapy; treatment outcome; rural; Tanzania