Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study

Ingle, Suzanne M; May, Margaret; Uebel, Kerry; Timmerman, Venessa; Kotze, Eduan; Bachmann, Max; Sterne, Jonathan A C; Egger, Matthias; Fairall, Lara (2010). Outcomes in patients waiting for antiretroviral treatment in the Free State Province, South Africa: prospective linkage study. AIDS, 24(17), pp. 2717-2725. Hagerstown, Md.: Lippincott Williams & Wilkins 10.1097/QAD.0b013e32833fb71f

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Objective: In South Africa, many HIV-infected patients experience delays in accessing
antiretroviral therapy (ART). We examined pretreatment mortality and access to
treatment in patients waiting for ART.
Design: Cohort of HIV-infected patients assessed for ART eligibility at 36 facilities
participating in the Comprehensive HIV and AIDS Management (CHAM) program in the
Free State Province.
Methods: Proportion of patients initiating ART, pre-ART mortality and risk factors
associated with these outcomes were estimated using competing risks survival analysis.
Results: Forty-four thousand, eight hundred and forty-four patients enrolled in CHAM
between May 2004 and December 2007, of whom 22 083 (49.2%) were eligible for
ART; pre-ART mortality was 53.2 per 100 person-years [95% confidence interval (CI)
51.8–54.7]. Median CD4 cell count at eligibility increased from 87 cells/ml in 2004 to
101 cells/ml in 2007. Two years after eligibility an estimated 67.7% (67.1–68.4%) of
patients had started ART, and 26.2% (25.6–26.9%) died before starting ART. Among
patients with CD4 cell counts below 25 cells/ml at eligibility, 48% died before ART and
51% initiated ART. Men were less likely to start treatment and more likely to die than
women. Patients in rural clinics or clinics with low staffing levels had lower rates of
starting treatment and higher mortality compared with patients in urban/peri-urban
clinics, or better staffed clinics.
Conclusions: Mortality is high in eligible patients waiting for ART in the Free State
Province. The most immunocompromised patients had the lowest probability of starting ART and the highest risk of pre-ART death. Prioritization of these patients should reduce waiting times and pre-ART mortality.

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