title: Outcomes of antiretroviral therapy over a 10-year period of expansion: a multicohort analysis of African and Asian HIV programs.
abstract: OBJECTIVE
  Little is known about the evolution of program outcomes associated with rapid expansion of antiretroviral therapy (ART) in resource-limited settings. We describe temporal trends and assess associations with mortality and loss to follow-up (LTFU) in HIV cohorts from 8 countries.
  
  
  METHODS
  Multicohort study using electronic health records.
  
  
  METHODS
  Analysis included adults in 25 Médecins Sans Frontières-supported programs initiating ART between 2001 and 2011. Kaplan-Meier methods were used to describe time to death or LTFU and proportional hazards models to assess associations with individual and program factors.
  
  
  RESULTS
  ART programs (n = 132,334, median age 35 years, 61% female) expanded rapidly. Whereas 36-month mortality decreased from 22% to 9% over 5 years (≤2003-2008), LTFU increased from 11% to 21%. Hazard ratios (HR) of early (0-12 months) and late (12-72 months) LTFU increased over time, from 1.09 [95% confidence interval (CI): 0.83 to 1.43] and 1.04 (95% CI: 0.84 to 1.28) in 2004 to 3.29 (95% CI: 2.42 to 4.46) and 6.86 (95% CI: 4.94 to 9.53) in 2011, compared with 2001-2003. Rate of program expansion was strongly associated with increased early and late LTFU, adjusted HR (aHR) = 2.31 (95% CI: 1.78 to 3.01) and HR = 2.29 (95% CI: 1.76 to 2.99), respectively, for ≥125 vs. 0-24 patients per month. Larger program size was associated with decreased early mortality (aHR = 0.49, 95% CI: 0.31 to 0.77 for ≥20,000 vs. <500 patients) and increased early LTFU (aHR = 1.77, 95% CI: 1.04 to 3.04 for ≥20,000 vs. <500 patients).
  
  
  CONCLUSIONS
  As ART expands in resource-limited settings, challenges remain in improving access to ART and preventing program attrition. There is an urgent need for novel and sustainable models of care to increase long-term retention of patients.
authors: *Division of Epidemiology & Biostatistics, School of Public Health & Family Medicine, University of Cape Town, Cape Town, South Africa; †Médecins Sans Frontières, Paris, France; ‡Médecins Sans Frontières, Amsterdam, Netherlands; §Médecins Sans Frontières, Geneva, Switzerland; ‖Médecins Sans Frontières, Cape Town, South Africa; ¶Epicentre, Paris, France; #Epicentre-Médecins Sans Frontières, Paris, France; and **University College London, London, United Kingdom.
authors: Anna
authors: A
authors: Grimsrud
authors: Suna
authors: S
authors: Balkan
authors: Esther C
authors: EC
authors: Casas
authors: Johnny
authors: J
authors: Lujan
authors: Gilles
authors: G
authors: Van Cutsem
authors: Elisabeth
authors: E
authors: Poulet
authors: Landon
authors: L
authors: Myer
authors: Mar
authors: M
authors: Pujades-Rodriguez
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D001208:Asia; D015331:Cohort Studies; D057286:Electronic Health Records / Q000706:statistics & numerical data; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality; D006297:Health Services Accessibility; D006801:Humans; D059012:Lost to Follow-Up; D008297:Male; D008875:Middle Aged; D016019:Survival Analysis; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents