Determinants of mortality and nondeath losses from an antiretroviral treatment service in South Africa: Implications for program evaluation
Clinical Infectious Diseases
Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa; Infectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa; Clinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States; Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd., Observatory 7925, Cape Town, South Africa
Background. The scale-up of antiretroviral treatment (ART) services in resource-limited settings requires a programmatic model to deliver care to large numbers of people. Understanding the determinants of key outcome measures-including death and nondeath losses-would assist in program evaluation and development. Methods. Between September 2002 and August 2005, all in-program (pretreatment and on-treatment) deaths and nondeath losses were prospectively ascertained among treatment-naive adults (n = 1235) who were enrolled in a community-based ART program in South Africa. Results. At study censorship, 927 patients had initiated ART after a median of 34 days after enrollment in the program. One hundred twenty-one (9.8%) patients died. Mortality rates were 33.3 (95% CI, 25.5-43.0), 19.1 (95% CI, 14.4-25.2), and 2.9 (95% CI, 1.8-4.8) deaths/100 person-years in the pretreatment interval, during the first 4 months of ART (early deaths), and after 4 months of ART (late deaths), respectively. Pretreatment and early treatment deaths together accounted for 87% of deaths, and were independently associated with advanced immunodeficiency at enrollment. Late deaths were comparatively few and were only associated with the response to ART at 4 months. Nondeath program losses (loss to follow-up, 2.3%; transfer-out, 1.9%; relocation, 0.7%) were not associated with immune status and were evenly distributed during the study period. Conclusions. Loss to follow-up and late mortality rates were low, reflecting good cohort retention and treatment response. However, the extremely high pretreatment and early mortality rates indicate that patients are enrolling in ART programs with far too advanced immunodeficiency. Causes of late access to the ART program, such as delays in health care access, health system delays, or inappropriate treatment criteria, need to be addressed. © 2006 by the Infectious Diseases Society of America. All rights reserved.
antiretrovirus agent; cotrimoxazole; dapsone; didanosine; efavirenz; lamivudine; lopinavir; nevirapine; ritonavir; RNA directed DNA polymerase inhibitor; stavudine; zidovudine; adult; article; female; health care; health care access; health care delivery; health care quality; health program; human; Human immunodeficiency virus infection; immune deficiency; major clinical study; male; mortality; priority journal; South Africa; Adult; Anti-Retroviral Agents; CD4 Lymphocyte Count; Cohort Studies; Female; Follow-Up Studies; HIV Infections; Humans; Male; Multivariate Analysis; Program Evaluation; Public Health Practice; Risk Assessment; South Africa; Treatment Failure