Background

IDI’s mandate includes offering advanced HIV/AIDS care and the development of cost-effective HIV care models. A key manifestation of this is IDI’s second-line ART clinic. This programme supports one of Africa’s largest cohorts of patients receiving second-line therapy (drugs taken after the development of resistance to first line therapy).  This cohort is being studied so that lessons learned can be shared with other facilities operating throughout sub-Saharan Africa.

Approaches Used

reatment of clients on first-line ART at IDI is monitored through clinical observation (for example general well being, weight changes, etc.) and immunological monitoring (for example changes in CD4 cell count). All clients undergo routine clinical immunological evaluations that are captured electronically and maintained in a database.  Through routine review of the clinic database, clients with a poor response to ART are identified and brought to the attention of a dedicated team of clinicians. These clients are then discussed individually in a weekly clinical forum called the Switch Meeting.

The purpose of the Switch Meeting is to review each client with the intention of making a recommendation about whether the client should continue first-line ART with modifications (including adherence support), undergo further evaluation of treatment response (viral load testing), or switch to second-line therapy. As a matter of policy, no IDI client is switched without such a discussion.  This ensures that highly informed and carefully considered treatment decisions are made, reducing the number of unnecessary switches, while also reducing delays when people do need to switch to second-line treatment. When the switch is made, the patient is entered into a second-line cohort where they undergo clinical, immunological and virologic monitoring.

This process is summarised in the following flowchart:

Key Accomplishments

IDI has one of the largest second-line cohorts in sub-Saharan Africa.  By the end of June 2009, there were 5,454 active clients on first-line ART (at the IDI clinic) and 520 on second line therapy. The evolution of ART categories at the institute is depicted in the following table:

The second-line cohort is already the platform for several prospective clinical studies.
The clinical, immunological and virological (levels of HIV virus in the blood) improvements in the second-line cohort have been remarkable. In an analysis of treatment responses at three years of second-line ART, 82% of the cohort had suppressed HIV to undetectable levels. The success of second-line treatment at IDI is best captured in the words of Mr. Peter Kalimba who has been on second-line treatment for the last three years:  “I have registered a tremendous improvement in my health since I was changed to second-line therapy. At the time of the switch, my weight was just 39kgs. I now weigh 60kgs. I am fortunate to have had a second chance. My life has truly been restored.”

Challenges and Opportunities

The number of IDI second-line clients targeted to be served by June 2010 is 750.
The high cost of viral load testing is not included in the routine clinical budget, at it is not part of the normal standard of care for Uganda.  As a result, timely identification of individuals who become resistant to first line treatment and require second line treatment is sometimes difficult. Solutions to bring down the cost of this important monitoring tool are urgently needed. In the meantime, IDI is generating a proposal that might fund the cost of this test for patients who appear to be failing on first-line treatment.
An additional challenge relates to side-effects.  According to an analysis of the second-line cohort over a three-year period, as many as 62% of patients on second-line therapy experience side effects. Safer second-line drugs are needed so that patients can continue treatment without developing additional health issues.