Share this article on:

Reduction in Early Mortality on Antiretroviral Therapy for Adults in Rural South Africa Since Change in CD4+ Cell Count Eligibility Criteria

Lessells, Richard J. MBChB*,†; Mutevedzi, Portia C. MSc*,‡; Iwuji, Collins C. MBBS, MSc*,§; Newell, Marie-Louise MB, MSc, PhD*,‖

JAIDS Journal of Acquired Immune Deficiency Syndromes: January 1st, 2014 - Volume 65 - Issue 1 - p e17–e24
doi: 10.1097/QAI.0b013e31829ceb14
Implementation and Operational Research: Epidemiology and Prevention
IOR articles

Objective: To explore the impact of expanded eligibility criteria for antiretroviral therapy (ART) on median CD4+ cell count at ART initiation and early mortality on ART.

Methods: Analyses included all adults (≥16 years) initiated on first-line ART between August 2004 and July 2012. CD4+ cell count threshold 350 cells per microliter for all adults was implemented in August 2011. Early mortality was defined as any death within 91 days of ART initiation. Trends in baseline CD4+ cell count and early mortality were examined by year (August to July) of ART initiation. Competing risks analysis was used to examine early mortality.

Results: A total of 19,080 adults (67.6% female) initiated ART. Median CD4+ cell count at ART initiation was 110–120 cells per microliter over the first 6 years, increasing marginally to 145 cells per microliter in 2010–2011 and more significantly to 199 cells per microliter in 2011–2012. Overall, there were 875 deaths within 91 days of ART initiation; early mortality rate was 19.4 per 100 person-years [95% confidence interval (CI) 18.2 to 20.7]. After adjustment for sex, age, baseline CD4+ cell count, and concurrent tuberculosis (TB), there was a 46% decrease in early mortality for those who initiated ART in 2011–2012 compared with the reference period 2008–2009 (subhazard ratio, 0.54; 95% CI: 0.41 to 0.71).

Conclusions: Since the expansion of eligibility criteria, there is evidence of earlier access to ART and a significant reduction in early mortality rate in this primary health care programme. These findings provide strong support for national ART policies and highlight the importance of earlier ART initiation for achieving reductions in HIV-related mortality.

Supplemental Digital Content is Available in the Text.

*Africa Centre for Health and Population Studies, University of KwaZulu-Natal, Somkhele, South Africa;

Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom;

Department of Infection and Population Health, University College London, London, United Kingdom;

§The Brighton Doctoral College, Brighton and Sussex Medical School, United Kingdom; and

University College London Institute of Child Health, London, United Kingdom.

Correspondence to: Richard J. Lessells, Africa Centre for Health and Population Studies, PO Box 198, Mtubatuba, KwaZulu-Natal 3935, South Africa (e-mail:

Supported by a core grant to the Africa Centre from the Wellcome Trust (082384/Z/07/Z; R.J.L. is supported by the Wellcome Trust (090999/Z/09/Z). The Hlabisa HIV Treatment and Care Programme have received support through the US Agency for International Development (USAID) and the President's Emergency Plan under the terms of Award 674-A-00-08-00-001-00. The opinions expressed herein are those of the authors and do not necessarily reflect the view of the USAID or the US government. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The authors have no conflicts of interest to disclose.

R.J.L., P.C.M., C.C.I., and M.L.N. conceived and designed the experiments. P.C.M. analyzed the data. R.J.L. wrote the first draft of the article. R.J.L., P.C.M., C.C.I., and M.L.N. interpreted the data and contributed to critical revision of the manuscript. R.J.L., P.C.M., C.C.I., and M.L.N. approved the final version of the manuscript. R.J.L., P.C.M., C.C.I., and M.L.N. met ICMJE criteria for authorship.

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 (

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

Received February 15, 2013

Accepted May 21, 2013

© 2014 by Lippincott Williams & Wilkins