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: 4.56). 11/2010; 56(1):e1-8. DOI: 10.1097/QAI.0b013e3181ff0bdc
Source: PubMed


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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    • "*Matovu, 2011 [17]. **Konate, [18]; Gusdal, [19]; Igumbor, [20]; Nglazi, [21]; Kipp, [22]; Wouters, [23]; Wouters, [24]; Shacham, [25]; Idoko, [26]; Nachega, [27]; Weidle, [28]. ‡ Naidoo, [29]. "
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    ABSTRACT: The success of adherence to combination antiretroviral therapy (cART) in sub-Saharan Africa is hampered by factors that are unique to this setting. Home based interventions have been identified as possible strategies for decentralizing ART care and improving access and adherence to cART. There is need for evidence at individual- or community-level of the benefits of home-based interventions in improving HIV suppression in African patients receiving cART. We conducted a systematic review and meta-analysis of the literature to assess the effect of home-based interventions on virologic outcomes in adults receiving cART in Africa. A total of 260 publications were identified by the search strategy, 249 were excluded on initial screening and 11 on full review, leaving 5 publications for analysis. The overall OR of virologic suppression at 12 months after starting cART of home-based interventions to standard of care was 1.13 (95% CI: 0.51-2.52). There was insufficient data to know whether there is a difference in HIV suppression at 12 months in the home-based arm compared with the standard of care arm in adults receiving cART in Africa. Given the few trials conducted from Africa, there is need for further research that measures the effects of home-based models on HIV suppression in African populations.
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    • "thereafter (Supplementary Table 1) [14, 15, 27, 28]. These base-case retention loss estimates exceed those reported by various South African cohorts with 5–6 years of follow-up data [29, 30]. In subsequent years (2005–2011), the numbers of persons assigned to start in each cohort were calculated such that the number of persons alive across all cohorts summed to UNAIDS-reported numbers of persons receiving ART in South Africa each year [1]. "
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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.
    Full-text · Article · Dec 2013 · The Journal of Infectious Diseases
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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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