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Similar Mortality and Reduced Loss to Follow-Up in Integrated Compared With Vertical Programs Providing Antiretroviral Treatment in Sub-Saharan Africa

Greig, Jane PhD, MAppEpid*; O'Brien, Daniel P. MBBS, FRACP†,‡,§; Ford, Nathan MPH, PhD*; Spelman, Tim MBBS, BSc, GradCert(Stats)‖,¶; Sabapathy, Kalpana MBBS, MRCP, MSc; Shanks, Leslie MD

JAIDS Journal of Acquired Immune Deficiency Syndromes: April 15th, 2012 - Volume 59 - Issue 5 - p e92–e98
doi: 10.1097/QAI.0b013e31824206c7
Implementation and Operational Research: Epidemiology and Prevention

Background: Vertical HIV programs have achieved good results but may not be feasible or appropriate in many resource-limited settings. Médecins sans Frontières has treated HIV in vertical programs since 2000 and over time integrated HIV treatment into general health care services using simplified protocols. We analyzed the survival probability among patients receiving antiretroviral therapy (ART) from 2003 to 2010 in integrated versus vertical programs in 9 countries in sub-Saharan Africa.

Methods and Findings: Cox regression assessed mortality and program design association, adjusting for baseline age, body mass index, clinical WHO stage, tuberculosis, program age and setting. The analysis included 15,403 HIV-positive adults on ART in 7 vertical (14,124 patients) and 10 integrated (1279 patients) programs. Cox regression including 14,523 patients followed for up to 30 months ART showed similar outcomes for mortality (adjusted hazard ratio (aHR) 1.02; 95% confidence interval (CI): 0.83 to 1.24) and lower risk of loss to follow-up (aHR: 0.71; 95% CI: 0.61 to 0.83) in integrated compared with vertical programs. The greatest risk of death was from initiating ART at WHO stage 4 (aHR 1.99, 95% CI: 1.74 to 2.29), although greater program experience was protective (aHR: 0.77, 95% CI: 0.66 to 0.89). Risk of loss to follow-up was greater in experienced programs (aHR: 3.33; 95% CI: 2.92 to 3.79) and rural settings (aHR: 3.82; 95% CI: 3.49 to 4.20).

Conclusions: ART delivery in integrated general health care programs results in good outcomes. Compared with vertical HIV programs, patients initiated ART in integrated programs at more advanced stages of clinical immunosuppression yet had similar risk of death and lower risk of loss to follow-up.

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*Manson Unit, Médecins sans Frontières, Saffron Hill, London, United Kingdom

Public Health Department, Médecins sans Frontières, Plantage Middenlaan, Amsterdam, The Netherlands

Department of Infectious Diseases, Geelong Hospital, Geelong, Australia

§Department of Medicine and Infectious Diseases, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia

Centre of Population Health, Burnet Institute, Melbourne, Victoria, Australia

Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia

Correspondence to: Dr Jane Greig, PhD, Médecins sans Frontières, 3rd floor, 67–74 Saffron Hill, London EC1N 8QX, United Kingdom (e-mail:

Presented at the International AIDS Conference, July 18–23, 2010, Vienna, Austria.

Author contributions: DOB conceived the study. JG, DOB, NF, TS and KS contributed to the analysis of the data. DOB, LS and JG wrote the first draft of the paper. NF, TS and KS contributed to the writing and review of the paper. All authors read and approved the final manuscript.

The authors have no funding or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (

Received July 11, 2011

Accepted October 28, 2011

© 2012 Lippincott Williams & Wilkins, Inc.