title: Improved antiretroviral treatment outcome in a rural African setting is associated with cART initiation at higher CD4 cell counts and better general health condition.
abstract: BACKGROUND
  Data on combination antiretroviral therapy (cART) in remote rural African regions is increasing.
  
  
  METHODS
  We assessed prospectively initial cART in HIV-infected adults treated from 2005 to 2008 at St. Francis Designated District Hospital, Ifakara, Tanzania. Adherence was assisted by personal adherence supporters. We estimated risk factors of death or loss to follow-up by Cox regression during the first 12 months of cART.
  
  
  RESULTS
  Overall, 1,463 individuals initiated cART, which was nevirapine-based in 84.6%. The median age was 40 years (IQR 34-47), 35.4% were males, 7.6% had proven tuberculosis. Median CD4 cell count was 131 cells/μl and 24.8% had WHO stage 4. Median CD4 cell count increased by 61 and 130 cells/μl after 6 and 12 months, respectively. 215 (14.7%) patients modified their treatment, mostly due to toxicity (56%), in particular polyneuropathy and anemia. Overall, 129 patients died (8.8%) and 189 (12.9%) were lost to follow-up. In a multivariate analysis, low CD4 cells at starting cART were associated with poorer survival and loss to follow-up (HR 1.77, 95% CI 1.15-2.75, p=0.009; for CD4<50 compared to >100 cells/μl). Higher weight was strongly associated with better survival (HR 0.63, 95% CI 0.51-0.76, p<0.001 per 10 kg increase).
  
  
  CONCLUSIONS
  cART initiation at higher CD4 cell counts and better general health condition reduces HIV related mortality in a rural African setting. Efforts must be made to promote earlier HIV diagnosis to start cART timely. More research is needed to evaluate effective strategies to follow cART at a peripheral level with limited technical possibilities.
authors.affiliation: St. Francis Designated District Hospital, Ifakara, United Republic of Tanzania.
authors.forename: Erik
authors.initials: E
authors.lastname: Mossdorf
authors.forename: Marcel
authors.initials: M
authors.lastname: Stoeckle
authors.forename: Emmanuel G
authors.initials: EG
authors.lastname: Mwaigomole
authors.forename: Evarist
authors.initials: E
authors.lastname: Chiweka
authors.forename: Patience L
authors.initials: PL
authors.lastname: Kibatala
authors.forename: Eveline
authors.initials: E
authors.lastname: Geubbels
authors.forename: Honoraty
authors.initials: H
authors.lastname: Urassa
authors.forename: Salim
authors.initials: S
authors.lastname: Abdulla
authors.forename: Luigia
authors.initials: L
authors.lastname: Elzi
authors.forename: Marcel
authors.initials: M
authors.lastname: Tanner
authors.forename: Hansjakob
authors.initials: H
authors.lastname: Furrer
authors.forename: Christoph
authors.initials: C
authors.lastname: Hatz
authors.forename: Manuel
authors.initials: M
authors.lastname: Battegay
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000276:immunology* / Q000401:mortality; D006304:Health Status; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D019829:Nevirapine / Q000627:therapeutic use; D011446:Prospective Studies; D012423:Rural Health / Q000706:statistics & numerical data; D013636:Tanzania / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D019829:Nevirapine