Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa.
OBJECTIVE
We report on outcomes after 7 years of a community-based antiretroviral therapy (ART) programme in Khayelitsha, South Africa, with death registry linkages to correct for mortality under-ascertainment.


METHODS
This is an observational cohort study.


METHODS
Since inception, patient-level clinical data have been prospectively captured on-site into an electronic patient information system. Patients with available civil identification numbers who were lost to follow-up were matched with the national death registry to ascertain their vital status. Corrected mortality estimates weighted these patients to represent all patients lost to follow-up. CD4 cell count outcomes were reported conditioned on continuous virological suppression.


RESULTS
Seven thousand, three hundred and twenty-three treatment-naive adults (68% women) started ART between 2001 and 2007, with annual enrolment increasing from 80 in 2001 to 2087 in 2006. Of 9.8% of patients lost to follow-up for at least 6 months, 32.8% had died. Corrected mortality was 20.9% at 5 years (95% confidence interval 17.9-24.3). Mortality fell over time as patients accessed care earlier (median CD4 cell count at enrolment increased from 43 cells/microl in 2001 to 131 cells/microl in 2006). Patients who remained virologically suppressed continued to gain CD4 cells at 5 years (median 22 cells/microl per 6 months). By 5 years, 14.0% of patients had failed virologically and 12.2% had been switched to second-line therapy.


CONCLUSIONS
At a time of considerable debate about future global funding of ART programmes in resource-poor settings, this study has demonstrated substantial and durable clinical benefits for those able to access ART throughout this period, in spite of increasing loss to follow-up.
Boulle
Andrew
A
School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Cape Town, South Africa. andrew.boulle@uct.ac.za
Van Cutsem
Gilles
G
Hilderbrand
Katherine
K
Cragg
Carol
C
Abrahams
Musaed
M
Mathee
Shaheed
S
Ford
Nathan
N
Knight
Louise
L
Osler
Meg
M
Myers
Jonny
J
Goemaere
Eric
E
Coetzee
David
D
Maartens
Gary
G
D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D003153:Community Health Services / Q000592:standards*; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D015497:HIV-1; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D015397:Program Evaluation; D011446:Prospective Studies; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome
D019380:Anti-HIV Agents