Article

Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa

School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Cape Town, South Africa.
AIDS (London, England) (Impact Factor: 6.56). 02/2010; 24(4):563-72. DOI: 10.1097/QAD.0b013e328333bfb7
Source: PubMed

ABSTRACT We report on outcomes after 7 years of a community-based antiretroviral therapy (ART) programme in Khayelitsha, South Africa, with death registry linkages to correct for mortality under-ascertainment.
This is an observational cohort study.
Since inception, patient-level clinical data have been prospectively captured on-site into an electronic patient information system. Patients with available civil identification numbers who were lost to follow-up were matched with the national death registry to ascertain their vital status. Corrected mortality estimates weighted these patients to represent all patients lost to follow-up. CD4 cell count outcomes were reported conditioned on continuous virological suppression.
Seven thousand, three hundred and twenty-three treatment-naive adults (68% women) started ART between 2001 and 2007, with annual enrolment increasing from 80 in 2001 to 2087 in 2006. Of 9.8% of patients lost to follow-up for at least 6 months, 32.8% had died. Corrected mortality was 20.9% at 5 years (95% confidence interval 17.9-24.3). Mortality fell over time as patients accessed care earlier (median CD4 cell count at enrolment increased from 43 cells/microl in 2001 to 131 cells/microl in 2006). Patients who remained virologically suppressed continued to gain CD4 cells at 5 years (median 22 cells/microl per 6 months). By 5 years, 14.0% of patients had failed virologically and 12.2% had been switched to second-line therapy.
At a time of considerable debate about future global funding of ART programmes in resource-poor settings, this study has demonstrated substantial and durable clinical benefits for those able to access ART throughout this period, in spite of increasing loss to follow-up.

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    • "The finding that disengagement from care has increased with each year of programme scale-up is of major concern: individuals enrolled on ART in 2010 and 2011 had more than double the risk of disengagement compared with those enrolled in 2004–2006. This supports findings from other programmes (Boulle et al. 2010; Fatti et al. 2011; Nglazi et al. 2011), although only one had corrected LTF for mortality (Boulle et al. 2010). This may reflect health systems struggling to cope with increasing patient load. "
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    ABSTRACT: Objective To determine rates of, and factors associated with, disengagement from care in a decentralised antiretroviral programme. Methods Adults (16years) who initiated antiretroviral therapy (ART) in the Hlabisa HIV Treatment and Care Programme August 2004-March 2011 were included. Disengagement from care was defined as no clinic visit for 180days, after adjustment for mortality. Cumulative incidence functions for disengagement from care, stratified by year of ART initiation, were obtained; competing-risks regression was used to explore factors associated with disengagement from care. ResultsA total of 4,674 individuals (median age 34years, 29% male) contributed 13610 person-years of follow-up. After adjustment for mortality, incidence of disengagement from care was 3.4 per 100 person-years (95% confidence interval (CI) 3.1-3.8). Estimated retention at 5years was 61%. The risk of disengagement from care increased with each calendar year of ART initiation (P for trend <0.001). There was a strong association between disengagement from care and higher baseline CD4+ cell count (subhazard ratio (SHR) 1.94 (P<0.001) and 2.35 (P<0.001) for CD4+ cell count 150-200 cells/l and >200 cells/l respectively, compared with CD4 count <50 cells/l). Of those disengaged from care with known outcomes, the majority (206/303, 68.0%) remained resident within the local community. Conclusions Increasing disengagement from care threatens to limit the population impact of expanded antiretroviral coverage. The influence of both individual and programmatic factors suggests that alternative service delivery strategies will be required to achieve high rates of long-term retention.
    Tropical Medicine & International Health 06/2013; 18(8). DOI:10.1111/tmi.12135 · 2.30 Impact Factor
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    • "The results of these approaches indicate that they can successfully improve access to ART with good quality. Pilot projects in Tanzania, Malawi, South Africa, Zambia and Mozambique show similar or improved treatment outcomes for PLWHA receiving decentralised care compared to hospitalbased care (Bemelmans et al., 2010; Boulle et al., 2010; Bussmann et al., 2008; Fox & Rosen, 2010; Lowrance et al., 2008; Nglazi et al., 2011; Stringer et al., 2006). "
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    ABSTRACT: There is growing attention for chronic diseases in sub-Saharan Africa (SSA) and for bridges between the management of HIV/AIDS and other (noncommunicable) chronic diseases. This becomes more urgent with increasing numbers of people living with both HIV/AIDS and other chronic conditions. This paper discusses the commonalities between chronic diseases by reviewing models of care, focusing on the two most dominant ones, diabetes mellitus type 2 (DM2) and HIV/AIDS. We argue that in order to cope with care for HIV patients and diabetes patients, health systems in SSA need to adopt new strategies taking into account essential elements of chronic disease care. We developed a “chronic dimension framework,” which analyses the “disease dimension,” the “health provider dimension,” the patient or “person dimension,” and the “environment dimension” of chronic diseases. Applying this framework to HIV/AIDS and DM2 shows that it is useful to think about management of both in tandem, comparing care delivery platforms and self-management strategies. A literature review on care delivery models for diabetes and HIV/AIDS in SSA revealed potential elements for cross-fertilisation: rapid scale-up approaches through the public health approach by simplification and decentralisation; community involvement, peer support, and self-management strategies; and strengthening health services.
    Journal of Tropical Medicine 10/2012; 2012:349312. DOI:10.1155/2012/349312
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    • "The provision of antiretroviral treatment has decreased morbidity and mortality in people living with HIV [3] [4] [5] [6] [7]. There have been several enabling factors for rapid scale-up of ART in resource-limited settings. "
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    ABSTRACT: Background. There has been a rapid scale up of antiretroviral therapy (ART) in Ethiopia since 2005. We aimed to evaluate mortality, loss to followup, and retention in care at HIV Clinic, University of Gondar Hospital, north-west Ethiopia. Method. A retrospective patient chart record analysis was performed on adult AIDS patients enrolled in the treatment program starting from 1 March 2005. We performed survival analysis to determine, mortality, loss to followup and retention in care. Results. A total of 3012 AIDS patients were enrolled in the ART Program between March 2005 and August 2010. At the end of the 66 months of the program initiation, 61.4% of the patients were retained on treatment, 10.4% died, and 31.4% were lost to followup. Fifty-six percent of the deaths and 46% of those lost to followup occurred in the first year of treatment. Male gender (adjusted hazard ratio (AHR) was 3.26; 95% CI: 2.19-4.88); CD4 count ≤200 cells/ μ L (AHR 5.02; 95% CI: 2.03-12.39), tuberculosis (AHR 2.91; 95% CI: 2.11-4.02); bed-ridden functional status (AHR 12.88; 95% CI: 8.19-20.26) were predictors of mortality, whereas only CD4 count <200 cells/ μ L (HR = 1.33; 95% CI: (0.95, 1.88) and ambulatory functional status (HR = 1.65; 95% CI: (1.22, 2.23) were significantly associated with LTF. Conclusion. Loss to followup and mortality in the first year following enrollment remain a challenge for retention of patients in care. Strengthening patient monitoring can improve patient retention AIDS care.
    06/2012; 2012:721720. DOI:10.5402/2012/721720
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