Abstract
IntroductionWhile increasing access to antiretroviral therapy (ART) is reported from many African countries, data on effective coverage particular from settings without external support or research remains scarce. We examined and report effective coverage data from a public ART program in rural Uganda.MethodsWe conducted a retrospective cohort study at all ART-providing governmental health facilities in Iganga District, Eastern Uganda. Based on all HIV patients registered between April 2004 and September 2009 (n = 4775), we assessed indicators of program performance and determined rates of retention and Cox proportional hazards for attrition. Effective ART coverage was calculated using projections (SPECTRUM software) adapted to the district demographic structure and number of people receiving ART.ResultsBy September 2009, district public sector effective ART coverage was 10.3% for adults and 1.9% for children. After a median follow-up of 26.9 months, overall ART retention was 54.7%. The probability of retention was 0.72 (95% confidence interval (CI) 0.69–0.75) at 12 and 0.58 (CI 0.54–0.62) at 36 months after ART initiation. Individual health facilities differed considerably regarding performance indicators and retention. Overall, 198 (16.9%) individual files of 1171 registered ART patients were lost. Young adult age (15–24 years) had a higher risk of attrition (HR 2.1, CI 1.4–3.2) as well as WHO stage I (HR 4.8, CI 1.9–11.8) and WHO stage IV (HR 2.5, CI 1.3–4.7). An interval ≥6 weeks between HIV testing and ART initiation was associated with a reduced risk (HR 0.6, CI 0.47–0.78).ConclusionCompared to reported national data effective ART coverage in Iganga District was low. Intensified efforts to improve access, retention in care, and quality of documentation are urgently needed. Children and young adults require special attention in the program.
Highlights
While increasing access to antiretroviral therapy (ART) is reported from many African countries, data on effective coverage particular from settings without external support or research remains scarce
Between April 2004 and 1st September 2009, 4775 patients had been registered in the Iganga District HIV program and 1171 (24.5%) patients had been started on ART, contributing to a total of 2462 person-years with a median follow-up time of 26.9 months since ART initiation
Program Evolution ART program characteristics are described in table 1
Summary
While increasing access to antiretroviral therapy (ART) is reported from many African countries, data on effective coverage particular from settings without external support or research remains scarce. We examined and report effective coverage data from a public ART program in rural Uganda. Over the last years, scaling up and decentralization of antiretroviral therapy (ART) programs have been achieved in many countries in Sub-Saharan Africa (SSA). Efforts to further scale up access to ART are supported by recent research showing an important risk reduction of HIV transmission under ART and the proposed strategy to use treatment as prevention. [6] as the scale-up process and expansion of ART coverage is going on, it appears that apart from still limited access to ART, the long-term retention under therapy constitutes a major challenge in SSA countries. For Uganda, a national ART coverage of 53.5% and a retention rate of over 80% at 24 months of ART have been reported. [14,15] Previous studies evaluating ART programs in Uganda are from faith-based settings [16], NGO-based settings [17,18,19,20], prospective research cohorts [18,19,20,21,22,23], or without inclusion of peripheral health centres (HC) [18,20,24] and give an incomplete picture of ART in rural Uganda
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