CART prescription trends in a prospective HIV cohort in rural Tanzania from 2007 to 2011

Abstract

Comprehensive information on combined antiretroviral therapy (cART) regimens in rural Sub‐Saharan Africa over time is scarce, particularly on the use of stavudine (d4T) and second‐line regimens. Since 2010, World Health Organization (WHO) guidelines discourage using stavudine in first‐line regimens due to frequent and severe side‐effects. This study examined the practical adaption of this phasing‐out and described trends in use of various cART combinations in a rural Tanzanian setting. We analyzed longitudinal, prospectively collected data of HIV‐1‐infected adults initiating cART within the Kilombero Ulanga Antiretroviral Cohort (KIULARCO) in Ifakara, Tanzania from 2007–2011. This analysis included data of 3068 patients over a 5‐year period. Of these subjects, 1997 (66.9%) were female, median age was 37 (interquartile range [IQR] 31–44) years and median CD4 cell count at enrollment was 178 cells/µl (IQR 88‐291). The percentage of prescriptions containing stavudine in initial regimens (Table 1) fell from a peak of 75% in 2008 to 12.2% in 2011 (p for trend<0.001). TDF/FTC/EFV became available in 2009 and was used in 117 (41.6%) patients initiating cART in 2011. An overall on‐treatment analysis (Figure 1) revealed that d4T/3TC/NVP and AZT/3TC/EFV were the most prescribed combinations in each year, including 2011 (684 [32.5%] and 642 [30.5%] patients respectively). Of those on d4T/3TC/NVP in 2011, 632 (92.4%) were initiated in earlier years. The ratio of second‐line to total regimens remained stable over time (p for trend=0.19) with a maximum of 34 (1.2%) patients in 2011, whereof 32 (94.1%) received a combination of ABC/ddI/LPVr.Overall on‐treatment count of patients on cART combinations by year.image Initial cART combinations prescribed by year. 2007 2008 2009 2010 2011 d4T/3TC/NVP 426 (66.6%) 536 536 (71.2%) 362 (46.8%) 93 (19.4%) 52 (12.2%) d4T/3TC/EFV 25 (3.9%) 29 (3.8%) 25 (3.2%) 6 (1.2%) 0 (0%) AZT/3TC/EFV 177 (27.7%) 174 (23.1%) 324 (41.9%) 160 (33.4%) 138 (32.4%) AZT/3TC/NVP 7 (1.1%) 10 (1.3%) 5 (0.6%) 21 (4.4%) 54 (12.7%) TDF/FTC/EFV 2 (0.3%) 2 (0.2%) 57 (7.3%) 199 (41.5%) 177 (41.6%) Total 639 752 773 479 425 Initial cART with stavudine declined to low levels according to recommendations but the overall use of stavudine remains substantial. The usage of second‐line treatment is unusually low in view of expected therapeutic failure rates, indicating potential difficulties in management of suspected treatment failure cases. Monitoring of prescription trends is a simple and feasible approach to identify deficits in the implementation of treatment guidelines for optimal outcomes.