Evaluation of antiretroviral therapy results in a resource-poor setting in Blantyre, Malawi


Joep J. van Oosterhout (corresponding author), Johnstone J. Kumwenda, Cooper Nyirenda, Jane Mallewa and Eduard E. Zijlstra, Department of Medicine, College of Medicine, Private Bag 360, Blantyre, Malawi. Tel.: +265-1-670202; Fax: +265-1-673933; E-mail: vanoosterhout@malawi.net or joosterhout@medcol.mw, jonnykumwenda@yahoo.com, tdnyirenda@sdnp.org.mw, jmallewa@jhu.medcol.mw, eezijlstra@malawi.net
Neena Bodasing, University Hospital of North Staffordshire, City General Hospital, Newcastle Road, Stoke-on Trent, UK. E-mail: neenabodasing@hotmail.com
Paul R. Cleary, Warrington PCT Headquarters, Birchwood, Warrington, UK. E-mail: paul.cleary@warrington-pct.nhs.uk
Michel P. de Baar, Primagen Holding BV, Meibergdreef 59, 1105 BA Amsterdam, The Netherlands. E-mail: m.p.debaar@primagen.com
Rob Schuurman, Laboratory of the Department of Virology (G04-615), University Medical Center Utrecht; Heidelberglaan 100, 3584 CX Utrecht, The Netherlands. E-mail: rob.schuurman@lab.azu.nl
David M. Burger, Department of Clinical Pharmacy, Radboud University Medical Centre Nijmegen, Geert Grooteplein 8, 6525 GA Nijmegen, The Netherlands. E-mail: d.burger@akf.umcn.nl


Objective  To evaluate treatment results of the paying antiretroviral therapy (ART) clinic of Queen Elizabeth Central Hospital, a large public and teaching hospital in Blantyre, Malawi. The only ART was a fixed drug combination of stavudine, lamivudine and nevirapine.

Methods  Cross sectional study with interviews, laboratory tests (CD4 count, viral load, nevirapine plasma levels, transaminases) and data extraction from files.

Results  A total of 422 (59%) of the patients who started ART since 2000 were lost to follow-up. The 176 patients enrolled in the study had good virological and excellent clinical treatment results. The most common side effect was peripheral neuropathy. Nevirapine plasma levels were remarkably high and associated with successful virological treatment results. Two simple adherence questions pertaining to the use of medication in the previous 8 days corresponded well with nevirapine levels. The most important reasons for non-adherence were shortage of drugs in the hospital pharmacy and personal financial constraints.

Conclusions  (1) Many patients were lost to follow-up. (2) High nevirapine levels contributed to good therapy results in those studied. (3) Simple adherence questions predicted subtherapeutic nevirapine levels. (4) Antiretroviral drug supply needs to be uninterrupted and free of charge, to prevent avoidable non-adherence.