Cohort Profile: The international epidemiological databases to evaluate AIDS (IeDEA) in sub-Saharan Africa

Abstract

The HIV/AIDS pandemic is a public health emergency in many low and middle-income countries. Out of the estimated 33.3 million people with HIV at the end of 2009, 22.5 million were in sub-Saharan Africa and the majority of these were women.1 The introduction in 1996 of combination anti-retroviral therapy (ART) led to a substantial reduction in morbidity and mortality in high-income countries.2,3 In more recent years, efforts by governmental programmes such as the President’s Emergency Program for AIDS Relief (PEPFAR) and The Global Fund as well as non-governmental programmes have resulted in the scale-up of ART in resource-limited settings: at the end of 2009, 5.25 million people were reported to be receiving ART therapy in low- and middle-income countries.1

Although still far from achieving universal coverage,1 the massive concerted scale-up of ART is unprecedented in global health. The long-term outcomes of ART in Africa and other regions are, however, not well defined. Poor retention in care, limited access to second-line ART regimens, co-infections and comorbidities of HIV infection, for example tuberculosis and cancer, and the emergence of drug resistance and toxicities are important challenges to long-term programme effectiveness in resource-limited settings.7 The World Health Organization (WHO) advocates a public health approach to ART in resource-limited settings, to maximize benefit in a setting of low levels of training for health-care workers, high patient burden and limited availability of drugs. Key characteristics include the standardization of first-line and second-line ART regimens, simplified clinical decision-making and standardized clinical and laboratory monitoring.4–6