Reduction in Early Mortality on Antiretroviral Therapy for Adults in Rural South Africa Since Change in CD4(+) Cell Count Eligibility Criteria

1Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa 2Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK 3Department of Infection and Population Health, University College London, UK 4The Brighton Doctoral College, Brighton and Sussex Medical School, UK 5University College London Institute of Child Health, London, UK.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.39). 06/2013; 65(1). DOI: 10.1097/QAI.0b013e31829ceb14
Source: PubMed

ABSTRACT OBJECTIVE:: To explore the impact of expanded eligibility criteria for antiretroviral therapy (ART) on median CD4+ cell count at ART initiation and early mortality on ART. METHODS:: Analyses included all adults (≥16 years) initiated on first-line ART between August 2004 and July 2012. CD4+ cell count threshold 350 cells/µL for all adults was implemented in August 2011. Early mortality was defined as any death within 91 days of ART initiation. Trends in baseline CD4+ cell count and early mortality were examined by year (August-July) of ART initiation. Competing-risks analysis was used to examine early mortality. RESULTS:: A total of 19 080 adults (67.6% female) initiated ART. Median CD4+ cell count at ART initiation was 110-120 cells/µL over the first six years, increasing marginally to 145 cells/µL in 2010/11 and more significantly to 199 cells/µL in 2011/12. Overall, there were 875 deaths within 91 days of ART initiation; early mortality rate 19.4 per 100 person-years (95% confidence interval (CI) 18.2-20.7). After adjustment for sex, age, baseline CD4+ cell count and concurrent TB, there was a 46% decrease in early mortality for those who initiated ART in 2011/12 compared to the reference period 2008/9 (sub-hazard ratio 0.54, 95% CI 0.41-0.71). CONCLUSIONS:: Since the expansion of eligibility criteria, there is evidence of earlier access to ART and a significant reduction in early mortality rates in this primary health care programme. These findings provide strong support for national ART policies and highlight the importance of earlier ART initiation for achieving reductions in HIV-related mortality.

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