Changes in Programmatic Outcomes During 7 Years of Scale-up at a Community-Based Antiretroviral Treatment Service in South Africa

The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.39). 11/2010; 56(1):e1-8. DOI: 10.1097/QAI.0b013e3181ff0bdc
Source: PubMed

ABSTRACT To assess sustainability of programmatic outcomes in a community-based antiretroviral therapy (ART) service in South Africa during 7 years of scale-up.
Prospective cohort of treatment-naive patients aged ≥ 15 years enrolled between 2002 and 2008. Data were analyzed by calendar period of ART initiation using time-to-event analysis and logistic regression.
ART was initiated by 3162 patients (67% women; median age, 34 years) who were followed-up for a median of 2.4 years (interquartile range, 1.2-3.8). After 6 years, the cumulative probability of death and loss to follow-up (LTFU) was 37.4%. The probabilities of transfer-out to another ART service and of virological failure were 21.6% and 23.1%, respectively. Low mortality risk and excellent virological and immunological responses during the first year of ART were not associated with calendar period of ART initiation. In contrast, risk of LTFU and virological failure both increased between successive calendar periods in unadjusted and adjusted analyses. The number of patients per member of clinic staff increased markedly over time.
Successful early outcomes (low mortality and good immunological and virological responses) were sustained between sequential calendar periods during 7 years of scale-up. In contrast, the increasing cumulative probabilities of LTFU or virological failure may reflect decreasing capacity to adequately support patients during long-term therapy as clinic caseload escalated.

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Available from: Richard Kaplan, Sep 12, 2014
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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.
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    • "As the current standard in healthcare delivery for the poor, community health work has been widely celebrated for its ability to improve the health of large numbers at a low cost (Igumbor et al., 2011; Kabore et al., 2010; Nglazi et al., 2011; Williams et al., 2006). But this success depends on the ability of careworkers to effectively negotiate a highly complex and onerous care 'manual' shaped by the divergent demands of patients, employers and funders; the arduous prescriptions of policy; and dominant public health practice. "
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    ABSTRACT: This paper forms part of a larger research project that explores how community health workers negotiate between the prescribed ‘manual’ for care and the realities of their field - re-appropriating prescriptions of public health policy through the micro-politics of everyday practice. Crucial to this question is how community health workers are able to disseminate the care manual authoritatively, despite their own authority being inherently unstable. This paper will discuss how careworkers negotiate authority in social and occupational contexts that regularly and powerfully undermine it. What tools, both discursive and otherwise, are at their disposal as they attempt to assert their authority as carers and measure up to those to whose authority they must submit? The paper shows that careworkers draw on a vast repertoire of discourses and performances in order to invoke, bargain for and appease authority. These series of improvisations are key to their survival on the job and necessitated by a care manual that is often impervious to social context.
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    JAIDS Journal of Acquired Immune Deficiency Syndromes 03/2011; 57(2):136-40. DOI:10.1097/QAI.0b013e3182199ee9 · 4.39 Impact Factor
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