Determinants of Mortality and Nondeath Losses from an Antiretroviral Treatment Service in South Africa: Implications for Program Evaluation

Department of Epidemiology, Columbia University, New York, New York, United States
Clinical Infectious Diseases (Impact Factor: 8.89). 10/2006; 43(6):770-6. DOI: 10.1086/507095
Source: PubMed


The scale-up of antiretroviral treatment (ART) services in resource-limited settings requires a programmatic model to deliver care to large numbers of people. Understanding the determinants of key outcome measures--including death and nondeath losses--would assist in program evaluation and development.
Between September 2002 and August 2005, all in-program (pretreatment and on-treatment) deaths and nondeath losses were prospectively ascertained among treatment-naive adults (n=1235) who were enrolled in a community-based ART program in South Africa.
At study censorship, 927 patients had initiated ART after a median of 34 days after enrollment in the program. One hundred twenty-one (9.8%) patients died. Mortality rates were 33.3 (95% CI, 25.5-43.0), 19.1 (95% CI, 14.4-25.2), and 2.9 (95% CI, 1.8-4.8) deaths/100 person-years in the pretreatment interval, during the first 4 months of ART (early deaths), and after 4 months of ART (late deaths), respectively. Pretreatment and early treatment deaths together accounted for 87% of deaths, and were independently associated with advanced immunodeficiency at enrollment. Late deaths were comparatively few and were only associated with the response to ART at 4 months. Nondeath program losses (loss to follow-up, 2.3%; transfer-out, 1.9%; relocation, 0.7%) were not associated with immune status and were evenly distributed during the study period.
Loss to follow-up and late mortality rates were low, reflecting good cohort retention and treatment response. However, the extremely high pretreatment and early mortality rates indicate that patients are enrolling in ART programs with far too advanced immunodeficiency. Causes of late access to the ART program, such as delays in health care access, health system delays, or inappropriate treatment criteria, need to be addressed.

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Available from: Robin Wood, Jul 10, 2014
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    • "A number of studies have identified demographic and clinical variables associated with mortality among ART patients. For instance, older ages and male sex are common demographic predictors of mortality in ART patients (Lawn et al. 2006; Agaba et al. 2011) while low CD4 counts, tuberculosis (TB) co-infection, anaemia and opportunistic infections have been found to increase mortality risks (Sani et al. 2006; Johannessen et al. 2008; Ogoina et al. 2012). The magnitude of the effects of these variables however varies from one setting to another depending on the epidemiology of HIV/AIDS and structural differences in HIV Counselling and Testing (HCT) and ART programmes (Braitstein et al. 2006). "
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    ABSTRACT: The first six months of HIV care and treatment are very important for long-term outcome. Early mortality (within 6 months of care initiation) undermines care and treatment goals. This study assessed the temporal distribution in baseline characteristics and early mortality among HIV patients at the University College Hospital, Ibadan, Nigeria from 2006-2013. Factors associated with early mortality were also investigated. This was a retrospective analysis of data from 14 857 patients enrolled for care and treatment at the adult antiretroviral clinic of the University College Hospital, Ibadan, Nigeria. Effects of factors associated with early mortality were summarised using a hazard ratio with a 95% confidence interval obtained from Cox proportional hazard regression models. The mean age of the subjects was 36.4 (SD=10.2) years with females being in the majority (68.1%). While patients' demographic characteristics remained virtually the same over time, there was significant decline in the prevalence of baseline opportunistic infections (2006-2007=55.2%; 2011-2013=38.0%). Overall, 460 (3.1%) patients were known to have died within 6 months of enrollment in care/treatment. There was no significant trend in incidence of early mortality. Factors associated with early mortality include: male sex, HIV encephalopathy, low CD4 count (< 50 cells), and anaemia. To reduce early mortality, community education should be promoted, timely access to care and treatment should be facilitated and the health system further strengthened to care for high risk patients.
    African Journal of AIDS Research 08/2015; DOI:10.2989/16085906.2015.1052526 · 0.79 Impact Factor
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    • "The latter scenarios assumed that 34% of eligible patients were not yet receiving ART [1], that the HIV-infected population size grew according to the projections by the Actuarial Society of South Africa [38], and that 10% of untreated eligible patients were linked to care each year. Maximum potential benefits from increased linkage to care were projected by examining alternative annual rates of linkage to care up to 84% [39]. "
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    ABSTRACT: Background: We sought to quantify the survival benefits attributable to antiretroviral therapy (ART) in South Africa since 2004. Methods: We used the Cost-Effectiveness of Preventing AIDS Complications-International model (CEPAC) to simulate 8 cohorts of human immunodeficiency virus (HIV)-infected patients initiating ART each year during 2004-2011. Model inputs included cohort-specific mean CD4(+) T-cell count at ART initiation (112-178 cells/µL), 24-week ART suppressive efficacy (78%), second-line ART availability (2.4% of ART recipients), and cohort-specific 36-month retention rate (55%-71%). CEPAC simulated survival twice for each cohort, once with and once without ART. The sum of the products of per capita survival differences and the total numbers of persons initiating ART for each cohort yielded the total survival benefits. Results: Lifetime per capita survival benefits ranged from 9.3 to 10.2 life-years across the 8 cohorts. Total estimated population lifetime survival benefit for all persons starting ART during 2004-2011 was 21.7 million life-years, of which 2.8 million life-years (12.7%) had been realized by December 2012. By 2030, benefits reached 17.9 million life-years under current policies, 21.7 million life-years with universal second-line ART, 23.3 million life-years with increased linkage to care of eligible untreated patients, and 28.0 million life-years with both linkage to care and universal second-line ART. Conclusions: We found dramatic past and potential future survival benefits attributable to ART, justifying international support of ART rollout in South Africa.
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    • "Very few studies have examined the effects of pre-ART baseline characteristics on early mortality after initiation of ART among Indian population, and reports from the developed world are not necessarily applicable to such resource limited settings. Nevertheless, mortality has been found to be high in these parts of the world, particularly the initial months after starting ART[7] [8] [9] [10] [11]. A better knowledge of the pre ART factors contributing to this high mortality can help implement targeted interventions among the high risk patients, thereby helping to reduce excess mortality. "
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