title: Temporal changes in programme outcomes among adult patients initiating antiretroviral therapy across South Africa, 2002-2007.
abstract: 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.
authors.affiliation: Centre for Infectious Disease Epidemiology & Research, University of Cape Town, South Africa. morna@global.co.za
authors.forename: Morna
authors.initials: M
authors.lastname: Cornell
authors.forename: Anna
authors.initials: A
authors.lastname: Grimsrud
authors.forename: Lara
authors.initials: L
authors.lastname: Fairall
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Fox
authors.forename: Gilles
authors.initials: G
authors.lastname: van Cutsem
authors.forename: Janet
authors.initials: J
authors.lastname: Giddy
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.forename: Hans
authors.initials: H
authors.lastname: Prozesky
authors.forename: Lerato
authors.initials: L
authors.lastname: Mohapi
authors.forename: Claire
authors.initials: C
authors.lastname: Graber
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
authors.forename: Landon
authors.initials: L
authors.lastname: Myer
mesh_terms: 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
chemical_list: D044966:Anti-Retroviral Agents