• Correcting for Mortality Among Patients Lost to Follow Up on Antiretroviral Therapy in South Africa: A Cohort Analysis

      Van Cutsem, Gilles; Ford, Nathan; Hildebrand, Katherine; Goemaere, Eric; Mathee, Shaheed; Abrahams, Musaed; Coetzee, David; Boulle, Andrew; Médecins Sans Frontières, South Africa; Centre for Infectious Disease Epidemiology and Research, University of Cape Town, South Africa, Department of Health, Provincial Government of the Western Cape, South Africa (2011-02-17)
      Loss to follow-up (LTF) challenges the reporting of antiretroviral treatment (ART) programmes, since it encompasses patients alive but lost to programme and deaths misclassified as LTF. We describe LTF before and after correction for mortality in a primary care ART programme with linkages to the national vital registration system.
    • Seven-year experience of a primary care antiretroviral treatment programme in Khayelitsha, South Africa.

      Boulle, Andrew; Van Cutsem, Gilles; Hilderbrand, Katherine; Cragg, Carol; Abrahams, Musaed; Mathee, Shaheed; Ford, Nathan; Knight, Louise; Osler, Meg; Myers, Jonny; Goemaere, Eric; Coetzee, David; Maartens, Gary; School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Cape Town, South Africa. andrew.boulle@uct.ac.za (2010-02-20)
      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/microl in 2001 to 131 cells/microl in 2006). Patients who remained virologically suppressed continued to gain CD4 cells at 5 years (median 22 cells/microl 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.