Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa.
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.
Full-textDOI: · Available from: Katherine Hilderbrand, Jun 16, 2015
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ABSTRACT: Achieving equitable access to health care is an important policy goal, with access influenced by affordability, availability, and acceptability of specific services. We explore patient narratives from a 5-year program of research on health care access to examine relationships between social constructions of illness and the acceptability of health services in the context of tuberculosis treatment and antiretroviral therapy in South Africa. Acceptability of services seems particularly important to the meanings patients attach to illness and care, whereas-conversely-these constructions appear to influence what constitutes acceptability and hence affect access to care. We highlight the underestimated role of individually, socially, and politically constructed healthworlds; traditional and biomedical beliefs; and social support networks. Suggested policy implications for improving acceptability and hence overall health care access include abandoning patronizing approaches to care and refocusing from treating "disease" to responding to "illness" by acknowledging and incorporating patients' healthworlds in patient-provider interactions. © The Author(s) 2015.Qualitative Health Research 05/2015; 25(5):622-35. DOI:10.1177/1049732315575315 · 2.19 Impact Factor
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ABSTRACT: Introduction: We studied patient outcomes by type of referral site following two years of combination antiretroviral therapy (cART) during scale-up from June 2006-July 2011 in Mozambique's rural Zambézia Province. Methods: Loss to follow-up (LTFU) was defined as no contact within 60 days after scheduled medication pickup. Endpoints included LTFU, mortality, and combined mortality/LTFU; we used Kaplan-Meier and cumulative incidence estimates. Referral site was the source of HIV testing. We modeled 2-year outcomes using Cox regression stratified by district, adjusting for sociodemographics and health status. Results: Of 7,615 HIV-infected patients >15 years starting cART, 61% were female and median age was 30 years. Two-year LTFU was 38.1% (95%CI: 36.9-39.3%) and mortality was 14.2% (95%CI 13.2%-15.2%). Patients arrived from voluntary counseling and testing (VCT) sites (51%), general outpatient clinic (21%), antenatal care (8%), inpatient care (3%), HIV/tuberculosis/laboratory facilities (<4%), or other sources of referral (14%). Compared with VCT, patients referred from inpatient, tuberculosis, or antenatal care had higher hazards of LTFU. Adjusted hazard ratios (AHR; 95%CI) for 2-year mortality by referral site (VCT as referent) were: inpatient 1.87 (1.36-2.58), outpatient 1.44 (1.11-1.85), and antenatal care 0.69 (0.43-1.11) and for mortality/LTFU were: inpatient 1.60 (1.34-1.91), outpatient 1.17 (1.02-1.33), tuberculosis care 1.38 (1.08-1.75), and antenatal care 1.24 (1.06-1.44). Discussion: That source of referral was associated with mortality/LTFU after adjusting for patient characteristics at cART initiation suggests that: 1) additional unmeasured factors are influential, and 2) retention programs may benefit from targeting patient populations based on source of referral with focused counseling and/or social support.AIDS Research and Human Retroviruses 11/2014; 31(2). DOI:10.1089/AID.2014.0007 · 2.46 Impact Factor
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ABSTRACT: Objective To ascertain estimates of adult patients, recorded as lost to follow-up (LTFU) within antiretroviral treatment (ART) programmes, who have self-transferred care, died or truly stopped ART in low- and middle-income countries.Methods PubMed, EMBASE, Web of Science, Science Direct, LILACS, IndMed and AIM databases (2003-2013) and IAS/AIDS conference abstracts (2011-2013) were searched for tracing studies reporting the proportion of traced patients found to have self-transferred, died or stopped ART. These estimates were then combined using random-effects meta-analysis. Risk of bias was assessed through subgroup and sensitivity analyses.Results28 studies were eligible for inclusion, reporting true outcomes for 10,806 traced patients attending approximately 258 ART facilities. None were from outside sub-Saharan Africa. 23 studies reported 4.5-54.4% traced LTFU patients self-transferring care, providing a pooled estimate of 18.6% (95% CI 15.8-22.0%). A significant positive association was found between rates of self-transfer and LTFU in the ART cohort. The pooled estimates for unreported deaths was 38.8% (95% CI 30.8-46.8%; 27 studies), and 28.6% (95% CI 21.9-36.0%; 20 studies) for patients stopping ART. A significant decrease in unreported deaths from 50.0% (95% CI 41.5-58.4%) to 30.0% (95% CI 21.1-38.9%) was found comparing study periods before and after 31/12/2007.Conclusions Substantial unaccounted for transfers and deaths among patients LTFU confirms that retention and mortality is underestimated where the true outcomes of LTFU patients are not ascertained.This article is protected by copyright. All rights reserved.Tropical Medicine & International Health 11/2014; 20(3). DOI:10.1111/tmi.12434 · 2.30 Impact Factor