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.
Design: 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.
*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.
Correspondence to: Anna Grimsrud, MPH, Office 5.36, Falmouth Building, Faculty of Health Sciences, University of Cape Town, Observatory 7925, Cape Town, South Africa (e-mail: firstname.lastname@example.org).
A.G. is supported by a Doctoral Foreign Study Award from the Canadian Institutes of Health Research and postgraduate bursary from the South African Centre of Excellence in Epidemiological Modelling and Analysis. L.M. is supported by an International Leadership Award from the Elizabeth Glaser Pediatric Foundation. For the remaining authors none were declared.
Presented previously at the seventh International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, July 1–3, 2013, Kuala Lumpur, Malaysia (Abstract #MOPE058), and the 17th International Workshop on HIV Observational Databases, April 11, 2013, Cavtat, Croatia (Abstract #17_98).
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Received December 04, 2013
Accepted May 23, 2014