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Evaluation of a Systematic Substitution of Zidovudine for Stavudine-Based HAART in a Program Setting in Rural Cambodia

Isaakidis, Petros MD, PhD*; Raguenaud, Marie-Eve MD, MSc*; Phe, Thong MD, MSc*; Khim, Sam A MD*; Kuoch, Sokhan MD; Khem, Sopheap*; Reid, Tony MD; Arnould, Line MD

JAIDS Journal of Acquired Immune Deficiency Syndromes: September 1st, 2008 - Volume 49 - Issue 1 - p 48-54
doi: 10.1097/QAI.0b013e31817bec19
Clinical Science

Objective: To evaluate a treatment strategy of substituting zidovudine (ZDV) for stavudine (d4T)-based highly active antiretroviral therapy (HAART), aimed at preventing d4T-associated toxicity, in a programmatic setting in rural Cambodia.

Methods: Survival probability, CD4 gain, anemia incidence, and factors associated with severe anemia were analyzed in a cohort of adult patients switched from d4T- to ZDV-containing regimens from March 2006 to March 2007.

Results: Among 527 patients systematically switched to ZDV after d4T-based HAART for a median of 18 months, 4 (0.8%) patients died, 2 (0.4%) were lost to follow-up, 18 (3.4%) were transferred out, and 503 (95.4%) remained on HAART. Median CD4 gain was +263.5 cells/μL (interquartile range: 89.25-369.5) at 24 months. Within 1 year after the switch, 21.9% and 7.1% of patients developed anemia (grades 1-4) and severe anemia (grades 3-4), respectively. Low body mass index (≤18) and low CD4 count (<200 cells/μL) at the time of switch were factors associated with severe anemia. Additional follow-up visits for laboratory monitoring and adherence counseling, increased absenteeism from work, and transportation costs for the patients were noted.

Conclusions: The switch strategy of substituting ZDV for d4T-based HAART led to satisfactory overall clinical outcomes. However, it resulted in a relatively high incidence of mild to severe anemia and increased burden for the program and the patients.

From the *Médecins Sans Frontières OCB, Phnom Penh, Cambodia; †Chronic Diseases Clinic, Donkeo Provincial Referral Hospital, Ministry of Health, Takeo, Cambodia; and ‡Médecins Sans Frontières OCB, Brussels, Belgium.

Received for publication January 10, 2008; accepted April 10, 2008.

Correspondence to: Dr. Petros Isaakidis, MD, PhD, Médecins Sans Frontières OCB, 72, Street 592, PO Box 840, Phnom Penh, Cambodia (e-mail:

© 2008 Lippincott Williams & Wilkins, Inc.