HIV antiretroviral therapy in Ethiopia. Overcoming implementation challenges

Abstract

Millions of people have died of HIV during the last 25 years. The highest number of deaths occurred in poor African countries where antiretroviral therapy was introduced only recently. Treating patients in settings with limited resources continues to be a challenge. The aim of this thesis was to improve antiretroviral therapy in Ethiopia. The main part of the thesis is based on a cohort of HIV infected patients at a district hospital in Ethiopia. We established the cohort before antiretroviral therapy was available in the country, and continued the follow-up afterwards. Additionally, we assessed the acceptability of HIV testing among tuberculosis patients. In untreated patients, death and tuberculosis incidence rates were high. HAART improved survival and decreased tuberculosis to a level similar to that achieved by developed countries during early years. However, both death and tuberculosis continued to occur at higher rate especially during the early weeks of treatment. Patients die because of advanced clinical disease stage and very low levels of total lymphocyte count at presentation. We also found that HIV testing was not accepted by most of the tuberculosis patients, highlighting the need for alternative and additional methods of testing more patients. Despite the limitations inherent in observational studies, the findings in this thesis provided useful data that can assist in the implementation of antiretroviral therapy in Ethiopia. To improve treatment outcomes, we need to treat patients before they progress to advanced stages. This requires improved counselling and testing practices, and making treatment available even in settings with limited laboratory setup. Future studies should examine the underlying reasons for death and mechanisms should be in place to further improve treatment outcomes.