title: Initiating antiretroviral therapy when presenting with higher CD4 cell counts results in reduced loss to follow-up in a resource-limited setting.
abstract: OBJECTIVE
  In August 2011, South Africa expanded its adult antiretroviral therapy (ART) guidelines to allow treatment initiation at CD4 cell values 350 cells/μl or less. Mortality and morbidity are known to be reduced when initiating at higher CD4 levels; we explored the impact on patient loss to follow-up.
  
  
  METHODS
  An observational cohort study.
  
  
  METHODS
  We analyzed routine data of 1430 adult patients initiating ART from April to December 2010 from a Johannesburg primary healthcare clinic offering ART initiation at CD4 cell count 350 cells/μl or less since 2010. We compared loss to follow-up (≥3 months late for the last scheduled visit), death, and incident tuberculosis within 1 year of ART initiation for those initiating at CD4 cell values 200 or less versus 201-350 cells/μl.
  
  
  RESULTS
  : Half (52.0%) of patients presented in the lower CD4 cell group [≤200 cells/μl, median: 105 cells/μl, interquartile range (IQR): 55-154] and initiated ART, and 48.0% in the higher group (CD4 cell count 201-350 cells/μl, median: 268 cells/μl, IQR: 239-307). The proportion of women and pregnant women was greater in the high CD4 cell group; the lower CD4 cell group included more patients with prevalent tuberculosis. Among men and nonpregnant women, initiating at 201-350 cells/μl was associated with 26-42% reduced loss to follow-up compared to those initiating 200 cells/μl or less. We found no CD4 cell effect among pregnant women. Risk of mortality [adjusted hazard ratio (aHR) 0.34, 95% confidence interval (CI) 0.13-0.84] and incident tuberculosis (aHR 0.44, 95% CI 0.23-0.85) was lower among the higher CD4 cell group.
  
  
  CONCLUSIONS
  This is one of the first studies from a routine clinical setting to demonstrate South Africa's 2011 expansion of ART treatment guidelines can be enacted without increasing program attrition.
authors.affiliation: Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa. kclouse@unc.edu
authors.forename: Kate
authors.initials: K
authors.lastname: Clouse
authors.forename: Audrey
authors.initials: A
authors.lastname: Pettifor
authors.forename: Mhairi
authors.initials: M
authors.lastname: Maskew
authors.forename: Jean
authors.initials: J
authors.lastname: Bassett
authors.forename: Annelies
authors.initials: A
authors.lastname: Van Rie
authors.forename: Cynthia
authors.initials: C
authors.lastname: Gay
authors.forename: Frieda
authors.initials: F
authors.lastname: Behets
authors.forename: Ian
authors.initials: I
authors.lastname: Sanne
authors.forename: Matthew P
authors.initials: MP
authors.lastname: Fox
mesh_terms: D017088:AIDS-Related Opportunistic Infections / Q000276:immunology* / Q000401:mortality / Q000517:prevention & control*; D000293:Adolescent; D000328:Adult; D019380:Anti-HIV Agents / Q000008:administration & dosage*; D018791:CD4 Lymphocyte Count; D015496:CD4-Positive T-Lymphocytes / Q000276:immunology*; D015331:Cohort Studies; D003695:Delivery of Health Care / Q000592:standards / Q000639:trends; D004522:Educational Status; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000276:immunology* / Q000401:mortality; D006295:Health Resources / Q000600:supply & distribution*; D006801:Humans; D015994:Incidence; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D011247:Pregnancy; D012189:Retrospective Studies; D018570:Risk Assessment; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors; D014397:Tuberculosis, Pulmonary / Q000209:etiology* / Q000276:immunology / Q000401:mortality / Q000517:prevention & control*; D019562:Viral Load
chemical_list: D019380:Anti-HIV Agents