title: Four-year treatment outcomes of adult patients enrolled in Mozambique's rapidly expanding antiretroviral therapy program.
abstract: BACKGROUND
  In Mozambique during 2004-2007 numbers of adult patients (≥15 years old) enrolled on antiretroviral therapy (ART) increased about 16-fold, from <5,000 to 79,500. All ART patients were eligible for co-trimoxazole. ART program outcomes, and determinants of outcomes, have not yet been reported.
  
  
  RESULTS
  In a retrospective cohort study, we investigated rates of mortality, attrition (death, loss to follow-up, or treatment cessation), immunologic treatment failure, and regimen-switch, as well as determinants of selected outcomes, among a nationally representative sample of 2,596 adults initiating ART during 2004-2007. At ART initiation, median age of patients was 34 and 62% were female. Malnutrition and advanced disease were common; 18% of patients weighed <45 kilograms, and 15% were WHO stage IV. Median baseline CD4(+) T-cell count was 153/µL and was lower for males than females (139/µL vs. 159/µL, p<0.01). Stavudine, lamivudine, and nevirapine or efavirenz were prescribed to 88% of patients; only 31% were prescribed co-trimoxazole. Mortality and attrition rates were 3.4 deaths and 19.8 attritions per 100 patient-years overall, and 12.9 deaths and 57.2 attritions per 100 patient-years in the first 90 days. Predictors of attrition included male sex [adjusted hazard ratio (AHR) 1.5; 95% confidence interval (CI), 1.3-1.8], weight <45 kg (AHR 2.1; 95% CI, 1.6-2.9, reference group >60 kg), WHO stage IV (AHR 1.7; 95% CI, 1.3-2.4, reference group WHO stage I/II), lack of co-trimoxazole prescription (AHR 1.4; 95% CI, 1.0-1.8), and later calendar year of ART initiation (AHR 1.5; 95% CI, 1.2-1.8). Rates of immunologic treatment failure and regimen-switch were 14.0 and 0.6 events per 100-patient years, respectively.
  
  
  CONCLUSIONS
  ART initiation at earlier disease stages and scale-up of co-trimoxazole among ART patients could improve outcomes. Research to determine reasons for low regimen-switch rates and increasing rates of attrition during program expansion is needed.
authors.affiliation: Division of Global AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America. aauld@cdc.gov
authors.forename: Andrew F
authors.initials: AF
authors.lastname: Auld
authors.forename: Francisco
authors.initials: F
authors.lastname: Mbofana
authors.forename: Ray W
authors.initials: RW
authors.lastname: Shiraishi
authors.forename: Mauro
authors.initials: M
authors.lastname: Sanchez
authors.forename: Charity
authors.initials: C
authors.lastname: Alfredo
authors.forename: Lisa J
authors.initials: LJ
authors.lastname: Nelson
authors.forename: Tedd
authors.initials: T
authors.lastname: Ellerbrock
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000494:pharmacology / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D015331:Cohort Studies; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D009073:Mozambique / Q000453:epidemiology; D010349:Patient Compliance; D012189:Retrospective Studies; D013997:Time Factors; D017211:Treatment Failure; D015430:Weight Gain / Q000187:drug effects
chemical_list: D019380:Anti-HIV Agents