title: Changes in programmatic outcomes during 7 years of scale-up at a community-based antiretroviral treatment service in South Africa.
abstract: OBJECTIVE
  To assess sustainability of programmatic outcomes in a community-based antiretroviral therapy (ART) service in South Africa during 7 years of scale-up.
  
  
  METHODS
  Prospective cohort of treatment-naive patients aged ≥ 15 years enrolled between 2002 and 2008. Data were analyzed by calendar period of ART initiation using time-to-event analysis and logistic regression.
  
  
  RESULTS
  ART was initiated by 3162 patients (67% women; median age, 34 years) who were followed-up for a median of 2.4 years (interquartile range, 1.2-3.8). After 6 years, the cumulative probability of death and loss to follow-up (LTFU) was 37.4%. The probabilities of transfer-out to another ART service and of virological failure were 21.6% and 23.1%, respectively. Low mortality risk and excellent virological and immunological responses during the first year of ART were not associated with calendar period of ART initiation. In contrast, risk of LTFU and virological failure both increased between successive calendar periods in unadjusted and adjusted analyses. The number of patients per member of clinic staff increased markedly over time.
  
  
  CONCLUSIONS
  Successful early outcomes (low mortality and good immunological and virological responses) were sustained between sequential calendar periods during 7 years of scale-up. In contrast, the increasing cumulative probabilities of LTFU or virological failure may reflect decreasing capacity to adequately support patients during long-term therapy as clinic caseload escalated.
authors.affiliation: The Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. mweete.nglazi@hiv-research.org.za
authors.forename: Mweete D
authors.initials: MD
authors.lastname: Nglazi
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Lawn
authors.forename: Richard
authors.initials: R
authors.lastname: Kaplan
authors.forename: Katharina
authors.initials: K
authors.lastname: Kranzer
authors.forename: Catherine
authors.initials: C
authors.lastname: Orrell
authors.forename: Robin
authors.initials: R
authors.lastname: Wood
authors.forename: Linda-Gail
authors.initials: LG
authors.lastname: Bekker
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods / Q000706:statistics & numerical data; D018791:CD4 Lymphocyte Count; D003153:Community Health Services / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D010352:Patient Dropouts / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D011446:Prospective Studies; D012307:Risk Factors; D013019:South Africa; D016896:Treatment Outcome; D019562:Viral Load / Q000187:drug effects / Q000706:statistics & numerical data; D016903:Drug Monitoring
chemical_list: D019380:Anti-HIV Agents