title: Mortality after failure of antiretroviral therapy in sub-Saharan Africa.
abstract: OBJECTIVE
  To assess the outcome of patients who experienced treatment failure with antiretrovirals in sub-Saharan Africa.
  
  
  METHODS
  Analysis of 11 antiretroviral therapy (ART) programmes in sub-Saharan Africa. World Health Organization (WHO) criteria were used to define treatment failure. All ART-naive patients aged >or=16 who started with a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen and had at least 6 months of follow-up were eligible. For each patient who switched to a second-line regimen, 10 matched patients who remained on a non-failing first-line regimen were selected. Time was measured from the time of switching, from the corresponding time in matched patients, or from the time of treatment failure in patients who remained on a failing regimen. Mortality was analysed using Kaplan-Meier curves and random-effects Cox models.
  
  
  RESULTS
  Of 16 591 adult patients starting ART, 382 patients (2.3%) switched to a second-line regimen. Another 323 patients (1.9%) did not switch despite developing immunological or virological failure. Cumulative mortality at 1 year was 4.2% (95% CI 2.2-7.8%) in patients who switched to a second-line regimen and 11.7% (7.3%-18.5%) in patients who remained on a failing first-line regimen, compared to 2.2% (1.6-3.0%) in patients on a non-failing first-line regimen (P < 0.0001). Differences in mortality were not explained by nadir CD4 cell count, age or differential loss to follow up.
  
  
  CONCLUSIONS
  Many patients who meet criteria for treatment failure do not switch to a second-line regimen and die. There is an urgent need to clarify the reasons why in sub-Saharan Africa many patients remain on failing first-line ART.
authors.affiliation: Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland. okeiser@ispm.unibe.ch
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
authors.forename: Hannock
authors.initials: H
authors.lastname: Tweya
authors.forename: Paula
authors.initials: P
authors.lastname: Braitstein
authors.forename: François
authors.initials: F
authors.lastname: Dabis
authors.forename: Patrick
authors.initials: P
authors.lastname: MacPhail
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
authors.forename: Denis
authors.initials: D
authors.lastname: Nash
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.forename: Ruedi
authors.initials: R
authors.lastname: Lüthi
authors.forename: Martin W G
authors.initials: MW
authors.lastname: Brinkhof
authors.forename: Mauro
authors.initials: M
authors.lastname: Schechter
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
mesh_terms: D000328:Adult; D017954:Africa South of the Sahara / Q000453:epidemiology; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods; D018791:CD4 Lymphocyte Count; D004812:Epidemiologic Methods; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality / Q000821:virology; D015497:HIV-1 / Q000302:isolation & purification*; D006801:Humans; D008297:Male; D017211:Treatment Failure; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents