Two-Year Virologic Outcomes of an Alternative AIDS Care Model: Evaluation of a Peer Health Worker and Nurse-Staffed Community-Based Program in Uganda

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Abstract
Background: There is growing concern about the human resources needed to care for increasing numbers of patients receiving antiretroviral therapy in resource-limited settings. We evaluated an alternative model, community-based, comprehensive antiretroviral program staffed primarily by peer health workers and nurses. Methods: We conducted a retrospective cohort study of patients receiving antiretroviral therapy during the first 10 months of program enrollment beginning in late 2003. Virologic, immunologic, clinical, and adherence data were collected. Results: Of 360 patients started on treatment, 258 (72%) were active and on therapy approximately 2 years later. Viral load testing demonstrated that 86% of active patients (211/246 tested) had a viral load <400 copies per milliliter. The median CD4 increase for active patients was 197 cells per cubic millimeter (interquartile range, 108-346). Patients with either a history of antiretroviral use or lack of CD4 response were more likely to experience virologic failure. Survival was 84% at 1 year and 82% at 2 years. World Health Organization stage 4 was predictive of both not sustaining therapy and increased mortality. Conclusions: A community-based antiretroviral treatment program in a resource-limited setting can provide excellent AIDS care over at least a 2-year period. A comprehensive program based upon peer health workers and nurses provides an effective alternative model for AIDS care.