JAIDS Journal of Acquired Immune Deficiency Syndromes:
Letters to the Editor
*Lux Development Centre Hospitalier de Kigali, Kigali, Rwanda, †Treatment and Research AIDS Center, Kigali, Rwanda, ‡Division de Toxicologie Laboratoire National de Santé, Luxembourg, §Laboratoire de Rétrovirologie, CRP-Santé, Luxembourg.
To the Editor:
We report our experience in the Ensemble de Solidarité Thérapeutique Hospitalière En Réseau (ESTHER) antiretroviral treatment program at the Center Hospitalier de Kigali in Kigali, Rwanda. The adherence to highly active antiretroviral therapy (HAART) has been assessed in the 95 patients first started on antiretroviral therapy; group 1 (n = 27) in May 2003 (zidovudine [ZDV] and lamivudine [3TC] sold as Avocomb [Ranbaxy, Gurgaon, India] and efavirenz [EFV] sold as Stocrin [Merck, Whitehouse Station, NJ]) and group 2 (n = 68) from September to December (stavudine [d4T], 3TC, and nevirapine [NVP] in fixed-dose combinations sold as Triomune or Triviro [depending on dosage of d4T] [Cipla, Mumbai, India]). We used a standardized questionnaire and performed therapeutic drug monitoring (TDM) for the nonnucleoside component of the regimen. Eighty percent of the patients were from a low socioeconomic status, and 98% of them were at an advanced stage of the HIV infection (World Health Organization [WHO] stage III or IV). More than 90% of the patients reported adverse effects. Five percent (5 of 95 patients) admitted to having forgotten 1 to 4 doses during the last 3 days. On a visual scale, 87% (83 of 95 patients) reported no missed dose during the last month, whereas 13% (12 of 95 patients) reported having taken “most” or “nearly all” the doses. TDM for group 1 showed detectable levels of EFV in 100% of the patients: 85% (23 of 27 patients) in the therapeutic range (1-4 μg/mL) and 15% (4 of 27 patients) slightly below (0.83-0.97 μg/mL). In the second group of patients who were taking Triomune or Triviro, blood samples were obtained from 41 persons; TDM showed that 93% (38 of 41 patients) were within the therapeutic range for NVP (>3 μg/mL), whereas 5% (2 of 41 patients) had an undetectable level. We concluded that a high level of treatment adherence, confirmed by TDM, was achieved despite the poverty, the adverse effects, and the advanced clinical stage of these patients. We have noticed that counseling and family support were essential to this success. From these results as well as from those obtained by Oyugi et al,1 we conclude that adherence rates equal to those in industrialized countries may be obtained in resource-limited settings. Meanwhile the scale-up ensures that more than 150 new patients are starting antiretroviral therapy each month at the main treatment clinic, and the challenge is to maintain similar levels of adherence with large numbers of patients followed.
Rémy Demeester, MD*
Jean Claude Karasi, MD†
Serge Schneider, MD‡
Jules Mugabo, MD*
Marie Josée Maliboli*
Vic Arendt, MD§
*Lux Development Centre Hospitalier de Kigali Kigali, Rwanda †Treatment and Research AIDS Center Kigali, Rwanda ‡Division de Toxicologie Laboratoire National de Santé Luxembourg, Grand-Duché de Luxembourg §Laboratoire de Rétrovirologie CRP-Santé Luxembourg, Grand-Duché de Luxembourg
1. Oyugi JH, Byakika-Tusiime JB, Charlebois ED, et al. Multiple validated measures of adherence indicate high levels of adherence to generic HIV antiretroviral therapy in a resource-limited setting. J Acquir Immune Defic Syndr