title: Early mortality among adults accessing a community-based antiretroviral service in South Africa: implications for programme design.
abstract: OBJECTIVE
  To determine rates, risk factors and causes of death among patients accessing a community-based antiretroviral treatment (ART) programme both prior to and following initiation of treatment.
  
  
  METHODS
  All in-programme deaths were ascertained between September 2002 and March 2005 among treatment-naive patients enrolled into a prospective community-based ART cohort in Cape Town, South Africa.
  
  
  RESULTS
  Of 712 patients (median CD4 cell count, 94 cells/microl), 578 (81%) started triple ART a median of 29 days after enrollment. 68 (9.5%) patients died during 563 person-years of observation. The high pretreatment mortality rate of 35.6 deaths/100 person-years [95% confidence interval (CI), 23.0-55.1) decreased to 2.5/100 person-years (95% CI, 0.9-6.6) at 1 year among those who received ART. However, within the first 90 days from enrollment, 29 of 44 (66%) deaths occurred among patients awaiting ART; these would not be identified by an on-treatment analysis. Multivariate analysis showed that risk of death (both pre-treatment and on-treatment) was independently associated with baseline CD4 cell count and World Health Organization (WHO) clinical stage; stage 4 disease was the strongest risk factor. Major attributed causes of death were wasting syndrome, tuberculosis, acute bacterial infections, malignancy and immune reconstitution disease.
  
  
  CONCLUSIONS
  Most early in-programme deaths occurred among patients with advanced immunodeficiency but who had not yet started ART. Programme evaluation using on-treatment analyses greatly underestimated early mortality. This mortality would be reduced by minimizing unnecessary in-programme delays in treatment initiation and by starting ART before development of WHO stage 4 disease.
authors.affiliation: The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Cape Town, South Africa. stevelawn@yahoo.co.uk
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Lawn
authors.forename: Landon
authors.initials: L
authors.lastname: Myer
authors.forename: Catherine
authors.initials: C
authors.lastname: Orrell
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
mesh_terms: D000293:Adolescent; D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D002423:Cause of Death; D003153:Community Health Services / Q000706:statistics & numerical data*; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D015996:Survival Rate