PLoS ONE (Jan 2015)

Uptake of WHO recommendations for first-line antiretroviral therapy in Kenya, Uganda, and Zambia.

  • Herbert C Duber,
  • Emily Dansereau,
  • Samuel H Masters,
  • Jane Achan,
  • Roy Burstein,
  • Brendan DeCenso,
  • Anne Gasasira,
  • Gloria Ikilezi,
  • Caroline Kisia,
  • Felix Masiye,
  • Pamela Njuguna,
  • Thomas Odeny,
  • Emelda Okiro,
  • D Allen Roberts,
  • Emmanuela Gakidou

DOI
https://doi.org/10.1371/journal.pone.0120350
Journal volume & issue
Vol. 10, no. 3
p. e0120350

Abstract

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IntroductionAntiretroviral therapy (ART) guidelines were significantly changed by the World Health Organization in 2010. It is largely unknown to what extent these guidelines were adopted into clinical practice.MethodsThis was a retrospective observational analysis of first-line ART regimens in a sample of health facilities providing ART in Kenya, Uganda, and Zambia between 2007-2008 and 2011-2012. Data were analyzed for changes in regimen over time and assessed for key patient- and facility-level determinants of tenofovir (TDF) utilization in Kenya and Uganda using a mixed effects model.ResultsData were obtained from 29,507 patients from 146 facilities. The overall percentage of patients initiated on TDF-based therapy increased between 2007-2008 and 2011-2012 from 3% to 37% in Kenya, 2% to 34% in Uganda, and 64% to 87% in Zambia. A simultaneous decrease in stavudine (d4T) utilization was also noted, but its use was not eliminated, and there remained significant variation in facility prescribing patterns. For patients initiating ART in 2011-2012, we found increased odds of TDF use with more advanced disease at initiation in both Kenya (odds ratio [OR]: 2.78; 95% confidence interval [CI]: 1.73-4.48) and Uganda (OR: 2.15; 95% CI: 1.46-3.17). Having a CD4 test performed at initiation was also a significant predictor in Uganda (OR: 1.43; 95% CI: 1.16-1.76). No facility-level determinants of TDF utilization were seen in Kenya, but private facilities (OR: 2.86; 95% CI: 1.45-5.66) and those employing a doctor (OR: 2.86; 95% CI: 1.48-5.51) were more likely to initiate patients on TDF in Uganda.Discussiond4T-based ART has largely been phased out over the study period. However, significant in-country and cross-country variation exists. Among the most recently initiated patients, those with more advanced disease at initiation were most likely to start TDF-based treatment. No facility-level determinants were consistent across countries to explain the observed facility-level variation.