title: Mortality associated with delays between clinic entry and ART initiation in resource-limited settings: results of a transition-state model.
abstract: OBJECTIVE
  To estimate the mortality impact of delay in antiretroviral therapy (ART) initiation from the time of entry into care.
  
  
  METHODS
  A state-transition Markov process model. This technique allows for assessing mortality before and after ART initiation associated with delays in ART initiation among a general population of ART-eligible patients without conducting a randomized trial.
  
  
  METHODS
  We used patient-level data from 3 South African cohorts to determine transition probabilities for pre-ART CD4 count changes and pre-ART and on-ART mortality. For each parameter, we generated probabilities and distributions for Monte Carlo simulations with 1-week cycles to estimate mortality 52 weeks from clinic entry.
  
  
  RESULTS
  We estimated an increase in mortality from 11.0% to 14.7% (relative increase of 34%) with a 10-week delay in ART for patients entering care with our pre-ART cohort CD4 distribution. When we examined low CD4 ranges, the relative increase in mortality delays remained similar; however, the absolute increase in mortality rose. For example, among patients entering with CD4 count 50-99 cells per cubic millimeter, 12-month mortality increased from 13.3% with no delay compared with 17.0% with a 10-week delay and 22.9% with a 6-month delay.
  
  
  CONCLUSIONS
  Delays in ART initiation, common in routine HIV programs, can lead to important increases in mortality. Prompt ART initiation for patients entering clinical care and eligible for ART, especially those with lower CD4 counts, could be a relatively low-cost approach with a potential marked impact on mortality.
authors: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21231, USA. choffmann@jhmi.edu
authors: Christopher J
authors: CJ
authors: Hoffmann
authors: James J
authors: JJ
authors: Lewis
authors: David W
authors: DW
authors: Dowdy
authors: Katherine L
authors: KL
authors: Fielding
authors: Alison D
authors: AD
authors: Grant
authors: Neil A
authors: NA
authors: Martinson
authors: Gavin J
authors: GJ
authors: Churchyard
authors: Richard E
authors: RE
authors: Chaisson
mesh_terms: D000554:Ambulatory Care Facilities / Q000706:statistics & numerical data*; D019380:Anti-HIV Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy / Q000401:mortality*; D006801:Humans; D008297:Male; D009010:Monte Carlo Method; D013019:South Africa / Q000453:epidemiology; D016019:Survival Analysis; D015996:Survival Rate; D013997:Time Factors
chemical_list: D019380:Anti-HIV Agents
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