Temporal changes in programme outcomes among adult patients initiating antiretroviral therapy across South Africa, 2002-2007.
OBJECTIVE
Little is known about the temporal impact of the rapid scale-up of large antiretroviral therapy (ART) services on programme outcomes. We describe patient outcomes [mortality, loss-to-follow-up (LTFU) and retention] over time in a network of South African ART cohorts.


METHODS
Cohort analysis utilizing routinely collected patient data.


METHODS
Analysis included adults initiating ART in eight public sector programmes across South Africa, 2002-2007. Follow-up was censored at the end of 2008. Kaplan-Meier methods were used to estimate time to outcomes, and proportional hazards models to examine independent predictors of outcomes.


RESULTS
Enrolment (n = 44 177, mean age 35 years; 68% women) increased 12-fold over 5 years, with 63% of patients enrolled in the past 2 years. Twelve-month mortality decreased from 9% to 6% over 5 years. Twelve-month LTFU increased annually from 1% (2002/2003) to 13% (2006). Cumulative LTFU increased with follow-up from 14% at 12 months to 29% at 36 months. With each additional year on ART, failure to retain participants was increasingly attributable to LTFU compared with recorded mortality. At 12 and 36 months, respectively, 80 and 64% of patients were retained.


CONCLUSIONS
Numbers on ART have increased rapidly in South Africa, but the programme has experienced deteriorating patient retention over time, particularly due to apparent LTFU. This may represent true loss to care, but may also reflect administrative error and lack of capacity to monitor movements in and out of care. New strategies are needed for South Africa and other low-income and middle-income countries to improve monitoring of outcomes and maximize retention in care with increasing programme size.
Cornell
Morna
M
Centre for Infectious Disease Epidemiology & Research, University of Cape Town, South Africa. morna@global.co.za
Grimsrud
Anna
A
Fairall
Lara
L
Fox
Matthew P
MP
van Cutsem
Gilles
G
Giddy
Janet
J
Wood
Robin
R
Prozesky
Hans
H
Mohapi
Lerato
L
Graber
Claire
C
Egger
Matthias
M
Boulle
Andrew
A
Myer
Landon
L
D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000276:immunology; D015497:HIV-1; D006801:Humans; D008297:Male; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D010342:Patient Acceptance of Health Care; D015397:Program Evaluation / Q000639:trends*; D013019:South Africa / Q000453:epidemiology; D055815:Young Adult
D044966:Anti-Retroviral Agents