Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomised non-inferiority trial.

BACKGROUND: HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa. METHODS: In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per microL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second-line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per microL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1.18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779. FINDINGS: Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85-88) in the CDM group and 90% (88-91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4.9 years' follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6.94 [95% CI 6.33-7.60] vs 5.24 [4.72-5.81] per 100 person-years; absolute difference 1.70 per 100 person-years [0.87-2.54]; HR 1.31 [1.14-1.51]; p=0.0001). Differences in disease progression occurred from the third year on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1.12 [0.94-1.32]; p=0.19), with anaemia the most common (76 vs 61 cases). INTERPRETATION: ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment. FUNDING: UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories.

People with HIV/AIDS going public

"To assess the impact of going public of people with HIV/AIDS (PWAs) as a strategy for HIV/AIDS behavioral change. The Philly Lutaaya Initiative was started in 1991 to enable PWAs to go public so as to create behavioral change in targeted audiences. In 1994; an evaluation was done to assess the impact of the strategy. Focus group discussion and open ended questionnaire data was collected from 62 PWAs; 72 opinion leaders and 80 audiences. The data was analyzed using qualitative methods. All the PWAs supported the strategy. The spirit of ""serving others"" and the ""always increasing acceptability"" are sources of encouragement to the PWAs. The relatives/friends of PWAs attitudes change gradually; becoming more positive. 69/70 of the friends/relatives recommended and supported the strategy. Audiences cited many benefits of going public including its power to initiate behavioral change and to empower the infected and the affected. Going public relied on publicity especially the ability to utilise community leaders. The PLI PWAs have not had any significant problem due to going public. The target audiences; relatives/friends and opinion leaders support and highlight the power of going public. Relatives and or friends of PWA's attitudes change gradually; becoming more positive."

People with HIV/AIDS going public

"To assess the impact of going public of people with HIV/AIDS (PWAs) as a strategy for HIV/AIDS behavioral change. The Philly Lutaaya Initiative was started in 1991 to enable PWAs to go public so as to create behavioral change in targeted audiences. In 1994; an evaluation was done to assess the impact of the strategy. Focus group discussion and open ended questionnaire data was collected from 62 PWAs; 72 opinion leaders and 80 audiences. The data was analyzed using qualitative methods. All the PWAs suppoted the strategy. The spirit of ""serving others"" and the ""always increasing acceptability"" are sources of encouragement to the PWAs. The relatives/friends of PWAs attitudes change gradually; becoming more positive. 69/70 of the friends/relatives recommended and supported the strategy. Audiences cited many benefits of going public including its power to initiate behavioral change and to empower the infected and the affected. Going public relied on publicity especially the ability to utilise community leaders. The PLI PWAs have not had any significant problem due to going public. The target audiences; relatives/friends and opinion leaders support and highlight the power of going public. Relatives and or friends of PWA's attitudes change gradually; becoming more positive."