title: Outcomes of antiretroviral treatment in programmes with and without routine viral load monitoring in Southern Africa.
abstract: OBJECTIVE
  To compare outcomes of antiretroviral therapy (ART) in South Africa, where viral load monitoring is routine, with those in Malawi and Zambia, where monitoring is based on CD4 cell counts.
  
  
  METHODS
  We included 18,706 adult patients starting ART in South Africa and 80,937 patients in Zambia or Malawi. We examined CD4 responses in models for repeated measures and the probability of switching to second-line regimens, mortality and loss to follow-up in multistate models, measuring time from 6 months.
  
  
  RESULTS
  In South Africa, 9.8% [95% confidence interval (CI) 9.1-10.5] had switched at 3 years, 1.3% (95% CI 0.9-1.6) remained on failing first-line regimens, 9.2% (95% CI 8.5-9.8) were lost to follow-up and 4.3% (95% CI 3.9-4.8) had died. In Malawi and Zambia, more patients were on a failing first-line regimen [3.7% (95% CI 3.6-3.9], fewer patients had switched [2.1% (95% CI 2.0-2.3)] and more patients were lost to follow-up [15.3% (95% CI 15.0-15.6)] or had died [6.3% (95% CI 6.0-6.5)]. Median CD4 cell counts were lower in South Africa at the start of ART (93 vs. 132 cells/μl; P < 0.001) but higher after 3 years (425 vs. 383 cells/μl; P < 0.001). The hazard ratio comparing South Africa with Malawi and Zambia after adjusting for age, sex, first-line regimen and CD4 cell count was 0.58 (0.50-0.66) for death and 0.53 (0.48-0.58) for loss to follow-up.
  
  
  CONCLUSIONS
  Over 3 years of ART mortality was lower in South Africa than in Malawi or Zambia. The more favourable outcome in South Africa might be explained by viral load monitoring leading to earlier detection of treatment failure, adherence counselling and timelier switching to second-line ART.
authors.affiliation: Division of International and Environmental Health, Institute of Social and Preventive Medicine, University of Bern, Switzerland. okeiser@ispm.unibe.ch
authors.forename: Olivia
authors.initials: O
authors.lastname: Keiser
authors.forename: Benjamin H
authors.initials: BH
authors.lastname: Chi
authors.forename: Thomas
authors.initials: T
authors.lastname: Gsponer
authors.forename: Andrew
authors.initials: A
authors.lastname: Boulle
authors.forename: Catherine
authors.initials: C
authors.lastname: Orrell
authors.forename: Sam
authors.initials: S
authors.lastname: Phiri
authors.forename: Nicola
authors.initials: N
authors.lastname: Maxwell
authors.forename: Mhairi
authors.initials: M
authors.lastname: Maskew
authors.forename: Hans
authors.initials: H
authors.lastname: Prozesky
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Fox
authors.forename: Andrew
authors.initials: A
authors.lastname: Westfall
authors.forename: Matthias
authors.initials: M
authors.lastname: Egger
mesh_terms: D000328:Adult; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D016001:Confidence Intervals; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000453:epidemiology / Q000276:immunology / Q000821:virology*; D015497:HIV-1 / Q000235:genetics / Q000276:immunology / Q000302:isolation & purification*; D006801:Humans; D008295:Malawi / Q000453:epidemiology; D008297:Male; D012367:RNA, Viral / Q000302:isolation & purification; D013019:South Africa / Q000453:epidemiology; D016896:Treatment Outcome; D019562:Viral Load; D015024:Zambia / Q000453:epidemiology
chemical_list: D019380:Anti-HIV Agents; D012367:RNA, Viral