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Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa

Boulle, Andrewa; Van Cutsem, Gillesa,b; Hilderbrand, Katherinea,b; Cragg, Carolc; Abrahams, Musaedb; Mathee, Shaheedc; Ford, Nathana,b; Knight, Louiseb; Osler, Mega; Myers, Jonnya; Goemaere, Ericb; Coetzee, Davida; Maartens, Garyd

doi: 10.1097/QAD.0b013e328333bfb7
Epidemiology and Social

Objectives: We report on outcomes after 7 years of a community-based antiretroviral therapy (ART) programme in Khayelitsha, South Africa, with death registry linkages to correct for mortality under-ascertainment.

Design: This is an observational cohort study.

Methods: Since inception, patient-level clinical data have been prospectively captured on-site into an electronic patient information system. Patients with available civil identification numbers who were lost to follow-up were matched with the national death registry to ascertain their vital status. Corrected mortality estimates weighted these patients to represent all patients lost to follow-up. CD4 cell count outcomes were reported conditioned on continuous virological suppression.

Results: Seven thousand, three hundred and twenty-three treatment-naive adults (68% women) started ART between 2001 and 2007, with annual enrolment increasing from 80 in 2001 to 2087 in 2006. Of 9.8% of patients lost to follow-up for at least 6 months, 32.8% had died. Corrected mortality was 20.9% at 5 years (95% confidence interval 17.9–24.3). Mortality fell over time as patients accessed care earlier (median CD4 cell count at enrolment increased from 43 cells/μl in 2001 to 131 cells/μl in 2006). Patients who remained virologically suppressed continued to gain CD4 cells at 5 years (median 22 cells/μl per 6 months). By 5 years, 14.0% of patients had failed virologically and 12.2% had been switched to second-line therapy.

Conclusion: At a time of considerable debate about future global funding of ART programmes in resource-poor settings, this study has demonstrated substantial and durable clinical benefits for those able to access ART throughout this period, in spite of increasing loss to follow-up.

aSchool of Public Health and Family Medicine, University of Cape Town, South Africa

bMédecins Sans Frontières, South Africa

cDepartment of Health, Provincial Government of the Western Cape, South Africa

dDepartment of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa.

Received 26 June, 2009

Revised 22 September, 2009

Accepted 1 October, 2009

Correspondence to Dr Andrew Boulle, MBChB, MSc, FCPHM(SA), School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory 7925, Cape Town, South Africa. Tel: +27 21 4066715; fax: +27 21 4066764; e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.