title: Overestimates of survival after HAART: implications for global scale-up efforts.
abstract: BACKGROUND
  Monitoring the effectiveness of global antiretroviral therapy scale-up efforts in resource-limited settings is a global health priority, but is complicated by high rates of losses to follow-up after treatment initiation. Determining definitive outcomes of these lost patients, and the effects of losses to follow-up on estimates of survival and risk factors for death after HAART, are key to monitoring the effectiveness of global HAART scale-up efforts.
  
  
  RESULTS
  A cohort study comparing clinical outcomes and risk factors for death after HAART initiation as reported before and after tracing of patients lost to follow-up was conducted in Botswana's National Antiretroviral Therapy Program. 410 HIV-infected adults consecutively presenting for HAART were evaluated. The main outcome measures were death or loss to follow-up within the first year after HAART initiation. Of 68 patients initially categorized as lost, over half (58.8%) were confirmed dead after tracing. Patient tracing resulted in reporting of significantly lower survival rates when death was used as the outcome and losses to follow-up were censored [1-year Kaplan Meier survival estimate 0.92 (95% confidence interval, 0.88-0.94 before tracing and 0.83 (95% confidence interval, 0.79-0.86) after tracing, log rank P<0.001]. In addition, a significantly increased risk of death after HAART among men [adjusted hazard ratio 1.74 (95% confidence interval, 1.05-2.87)] would have been missed had patients not been traced [adjusted hazard ratio 1.41 (95% confidence interval, 0.65-3.05)].
  
  
  CONCLUSIONS
  Due to high rates of death among patients lost to follow-up after HAART, survival rates may be inaccurate and important risk factors for death may be missed if patients are not actively traced. Patient tracing and uniform reporting of outcomes after HAART are needed to enable accurate monitoring of global HAART scale-up efforts.
authors.affiliation: University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA. gregbisson@mac.com
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Bisson
authors.forename: Tendani
authors.initials: T
authors.lastname: Gaolathe
authors.forename: Robert
authors.initials: R
authors.lastname: Gross
authors.forename: Caitlin
authors.initials: C
authors.lastname: Rollins
authors.forename: Scarlett
authors.initials: S
authors.lastname: Bellamy
authors.forename: Mpho
authors.initials: M
authors.lastname: Mogorosi
authors.forename: Ava
authors.initials: A
authors.lastname: Avalos
authors.forename: Harvey
authors.initials: H
authors.lastname: Friedman
authors.forename: Diana
authors.initials: D
authors.lastname: Dickinson
authors.forename: Ian
authors.initials: I
authors.lastname: Frank
authors.forename: Ndwapi
authors.initials: N
authors.lastname: Ndwapi
mesh_terms: D000328:Adult; D000368:Aged; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate
chemical_list: D019380:Anti-HIV Agents