title: Incidence of WHO stage 3 and 4 conditions following initiation of anti-retroviral therapy in resource limited settings.
abstract: OBJECTIVE
  To determine the incidence of WHO clinical stage 3 and 4 conditions during early anti-retroviral therapy (ART) in resource limited settings (RLS).
  
  
  METHODS
  A descriptive analysis of routine program data collected prospectively from 25 Médecins Sans Frontières supported HIV treatment programs in eight countries between 2002 and 2010.
  
  
  METHODS
  35,349 study participants with median follow-up on ART of 1.33 years (IQR 0.51-2.41).
  
  
  METHODS
  Incidence in 100 person-years of WHO stage 3 or 4 conditions during 5 periods after ART initiation. Diagnoses of conditions were made according to WHO criteria and relied upon clinical assessments supported by basic laboratory investigations.
  
  
  RESULTS
  The incidence of any WHO clinical stage 3 or 4 condition over 3 years was 40.02 per 100 person-years (31.77 for stage 3 and 8.25 for stage 4). The incidence of stage 3 and 4 conditions fell by over 97% between months 0-3 and months 25-36 (77.81 to 2.40 for stage 3 and 28.70 to 0.64 for stage 4). During months 0-3 pulmonary tuberculosis was the most common condition diagnosed in adults (incidence 22.24 per 100 person-years) and children aged 5-14 years (25.76) and oral candidiasis was the most common in children <5 years (25.79). Overall incidences were higher in Africa compared with Asia (43.98 versus 12.97 for stage 3 and 8.98 versus 7.05 for stage 4 conditions, p<0.001). Pulmonary tuberculosis, weight loss, oral and oesophageal candidiasis, chronic diarrhoea, HIV wasting syndrome and severe bacterial infections were more common in Africa. Extra-pulmonary tuberculosis, non-tuberculous mycobacterial infection, cryptococcosis, penicilliosis and toxoplasmosis were more common in Asia.
  
  
  CONCLUSIONS
  The incidence of WHO stage 3 and 4 conditions during the early period after ART initiation in RLS is high, but greatly reduces over time. This is likely due to both the benefits of ART and deaths of the sickest patients occurring shortly after ART initiation. Access to appropriate disease prevention tools prior to ART, and early initiation of ART, are important for their prevention.
authors.affiliation: Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors.forename: Andrea J
authors.initials: AJ
authors.lastname: Curtis
authors.forename: Catherine S
authors.initials: CS
authors.lastname: Marshall
authors.forename: Tim
authors.initials: T
authors.lastname: Spelman
authors.forename: Jane
authors.initials: J
authors.lastname: Greig
authors.forename: Julian H
authors.initials: JH
authors.lastname: Elliot
authors.forename: Leslie
authors.initials: L
authors.lastname: Shanks
authors.forename: Philipp
authors.initials: P
authors.lastname: Du Cros
authors.forename: Esther C
authors.initials: EC
authors.lastname: Casas
authors.forename: Marcio Silveria
authors.initials: MS
authors.lastname: Da Fonseca
authors.forename: Daniel P
authors.initials: DP
authors.lastname: O'Brien
mesh_terms: D000328:Adult; D000349:Africa; D000367:Age Factors; D044966:Anti-Retroviral Agents; D001208:Asia; D018791:CD4 Lymphocyte Count; D003906:Developing Countries; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy* / Q000453:epidemiology; D006295:Health Resources; D006801:Humans; D015994:Incidence; D008297:Male; D012720:Severity of Illness Index
chemical_list: D044966:Anti-Retroviral Agents