title: Differences in access and patient outcomes across antiretroviral treatment clinics in the Free State province: a prospective cohort study.
abstract: OBJECTIVE
  To assess differences in access to antiretroviral treatment (ART) and patient outcomes across public sector treatment facilities in the Free State province, South Africa.
  
  
  METHODS
  Prospective cohort study with retrospective database linkage. We analysed data on patients enrolled in the treatment programme across 36 facilities between May 2004 and December 2007, and assessed percentage initiating ART and percentage dead at 1 year after enrolment. Multivariable logistic regression was used to estimate associations of facility-level and patient-level characteristics with both mortality and treatment status.
  
  
  RESULTS
  Of 44 866 patients enrolled, 15 219 initiated treatment within 1 year; 8 778 died within 1 year, 7 286 before accessing ART. Outcomes at 1 year varied greatly across facilities and more variability was explained by facility-level factors than by patient-level factors. The odds of starting treatment within 1 year improved over calendar time. Patients enrolled in facilities with treatment initiation available on site had higher odds of starting treatment and lower odds of death at 1 year compared with those enrolled in facilities that did not offer treatment initiation. Patients were less likely to start treatment if they were male, severely immunosuppressed (CD4 count ≤50 cells/µl), or underweight (<50 kg). Men were also more likely to die in the first year after enrolment.
  
  
  CONCLUSIONS
  Although increasing numbers of patients started ART between 2004 and 2007, many patients died before accessing ART. Patient outcomes could be improved by decentralisation of treatment services, fast-tracking the most immunodeficient patients and improving access, especially for men.
authors.affiliation: Department of Social Medicine, University of Bristol, UK. S.Ingle@bristol.ac.uk
authors.forename: Suzanne M
authors.initials: SM
authors.lastname: Ingle
authors.forename: Margaret
authors.initials: M
authors.lastname: May
authors.forename: Kerry
authors.initials: K
authors.lastname: Uebel
authors.forename: Venessa
authors.initials: V
authors.lastname: Timmerman
authors.forename: Eduan
authors.initials: E
authors.lastname: Kotze
authors.forename: Max
authors.initials: M
authors.lastname: Bachmann
authors.forename: Jonathan A C
authors.initials: JA
authors.lastname: Sterne
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
authors.forename: Lara
authors.initials: L
authors.lastname: Fairall
mesh_terms: D000293:Adolescent; D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D015658:HIV Infections / Q000401:mortality; D006296:Health Services / Q000600:supply & distribution; D006801:Humans; D008297:Male; D011446:Prospective Studies; D013019:South Africa; D016896:Treatment Outcome
chemical_list: D044966:Anti-Retroviral Agents