State of the ART: clinical efficacy and improved quality of life in the public antiretroviral therapy program, Free State province, South Africa

Abstract

The South African public-sector antiretroviral treatment (ART) program has yielded promising early results. To extend and reinforce these preliminary findings, we undertook a detailed assessment of the clinical efficacy and outcomes over two years of ART. The primary objective was to assess the clinical outcomes and adverse effects of two years of ART, while identifying the possible effects of baseline health and patient characteristics. A secondary objective was to address the interplay between positive and negative outcomes (clinical benefits versus adverse effects) in terms of the patients’ physical and emotional quality of life (QoL). Clinical outcome, baseline characteristics, health status, and physical and emotional QoL scores were determined from clinical files and interviews with 268 patients enrolled in the Free State ART program at three time points (6, 12, and 24 months of ART). Age, sex, education, and baseline health (CD4 cell count and viral load) were all independently associated with the ART outcome in the early stages of treatment, but their impact diminished as the treatment progressed. The number of patients classified as treatment successes increased over the first two years of ART, whereas the proportion of patients experiencing adverse effects diminished. Importantly, our findings show that ART had strong and stable positive effects on physical and emotional QoL. These favorable results demonstrate that a well-managed public-sector ART program can be very successful within a high-HIV-prevalence resource-limited setting. This finding emphasizes the need to adopt treatment scale-up as a key policy priority, while at the same time ensuring that the highest standards of healthcare provision are maintained. Healthcare services should also target vulnerable groups (males, less-educated patients, those with low baseline CD4 cell counts, and high baseline viral loads) who are most likely to experience treatment failure.

Keywords:

• HIV/AIDS
• antiretroviral treatment
• clinical outcomes
• quality of life
• South Africa

Acknowledgements

This study was funded by the Research Foundation of Flanders, the International Development Research Center of Canada, the Joint Economics, AIDS and Poverty Programme (with the support of the Australian Agency for International Development, the United States Agency for International Development, the Department for International Development, and the United Nations Development Program), and the National Research Foundation of South Africa.

Notes

1. Almost all patients (97.8%) received a regimen consisting either stavudine, lamivudine, and efavirenz, or stavudine, lamivudine, and nevirapine. Bivariate analysis showed no statistical differences in the study variables (ART outcomes, adverse effects, physical and emotional QoL) between the two regimens.

2. A patient's physical QoL cannot be directly and reliably measured by asking one question. This is called a “latent concept.” Such constructs can only be measured indirectly by observable indicators, such as questionnaire items designed to measure various physical capacities of the patient. We can then compile one construct expressing the patient's physical QoL from these items.

3. EuroQoL also includes a “thermometer” of overall health, the visual analogue scale. The visual analogue scale is a measure of generic health and was therefore omitted from the analysis.