Outcomes in a Cohort of Patients Started on Antiretroviral Treatment and Followed up for a Decade in an Urban Clinic in Uganda

Abstract

BackgroundShort-medium term studies from sub-Saharan Africa show that, despite high early mortality, substantial loss to program, and high rates toxicity, patients on antiretroviral treatment have achieved outcomes comparable to those in developed settings. However, these studies were unable to account for long term outcomes of patients as they stayed longer on treatment.ObjectivesWe aim to describe ten years outcomes of one of the first cohort of HIV positive patients started on antiretroviral treatment (ART) in Sub-Saharan Africa.MethodsWe report 10-years outcomes including mortality, retention, CD4-count response, virological outcomes, ART regimens change from a prospective cohort of 559 patients initiating ART and followed up for 10 years Uganda.ResultsOf 559 patients, 69.1% were female, median age (IQR) was 38 (33–44) years, median CD4-count (IQR) 98 (21–163) cell/μL; 74% were started on stavudine, lamivudine and nevirapine, 26% on zidovudine, lamivudine and efavirenz. After 10 years 361 (65%) patients were still in the study; 127 (22.7%) had died; 30 (5%) were lost to follow-up; 27 (5%) transferred; 18 (3%) withdrew consent. The probability of death was high in the first year (0.15, 95%, CI 0.12–0.18). The median CD4 count increased from 98 to 589 cell/μL (IQR: 450–739 cell/μL) with a median increase of 357 cells/μL (IQR: 128–600 cells/μL); 7.4% never attained initial viral suppression and of those who did 31.7% experienced viral failure. Three hundred and two patients had at least one drug substitution while on first line after a median of 40 months; 66 (11.9%) of the patients were switched to a second line PI-based regimen due to confirmed treatment failure.ConclusionsDespite the high rate of early mortality due to advanced disease at presentation the outcomes from this cohort are encouraging, particularly the remarkable and incremental immune-recovery and a satisfactory rate of virologic suppression.

Safety of monitoring antiretroviral therapy response in HIV-1 infection using CD4+ T cell count at long-term intervals

“…This explains the progressive increase in CD4+ T cells observed from one year to the other in all three groups of patients of this study. This result is consistent with a study carried out in an Ugandan cohort where CD4+ T cell levels increased continuously throughout the 10-year follow-up, and 83.8% of the patients reached CD4+ T cell amounts above the lower reference value 19 . In an Asian study with 6,521 HIV-1-infected patients, there was a positive increase over time in CD4+ T cells gains and in the proportion of patients with VL suppression 20 .…”

“My future is bright…I won't die with the cause of AIDS”: ten‐year patient ART outcomes and experiences in South Africa

“…When those who transferred out of the facility are excluded, ten‐year mortality is slightly higher at 25.4% and LTF, although still in range compared to other studies, is also higher at 39.6%. Lower rates of mortality and LTF seen in some studies may be the result of intensive monitoring and enhanced patient retention interventions, including counselling, appointment reminders and active tracing . Additionally, linking our mortality data to the VRS would have resulted in higher mortality than observed in patient files, as demonstrated by previous work done by our group that found that 37% of those lost to follow‐up had actually died .…”

“…This 12-month retention rate is comparable to the 77% summarized retention in a meta-analysis using 2008 to 2013 LMIC data [38]. Few sub-Saharan African studies have reported data on longterm ART outcomestwo from Nigeria (ten-and seven-year follow-up), one from Uganda (ten-year follow-up), one from Zimbabwe (ten-year follow-up), one from Mozambique (nineyear follow-up) and one from South Africa (twelve-year followup) [23][24][25][26][27][28]. These studies show mixed results, with retention ranging from 37% to 83%, mortality from 1% to 24% and LTF from 5% to 51%; our observed ten-year 18.5% mortality and 28.8% LTF from the initiating clinic lie within these ranges "Yes, they give me a counselling.…”

“…Substantial research has investigated the short-and medium-term clinical outcomes of people on ART and these studies demonstrate favourable treatment outcomes for cohorts in low-and middle-income countries (LMICs) [11][12][13][14][15][16][17][18][19][20][21][22]. More recently, several studies in low-resource settings have published longer term outcomes [23][24][25][26][27]; however, in South Africa, apart from two longer term studies [17,28], little is yet known about treatment outcomes beyond the first five years on ART in this context and retention-in-care remains suboptimal [29]. Even less is known about the experiences and perceptions of people who have been on treatment since the start of the programme and how these may have changed as the dramatic effects of ART became commonplace.…”

The value of point-of-care CD4+ and laboratory viral load in tailoring antiretroviral therapy monitoring strategies to resource limitations

“…If ART suppression or re-suppression rates are high (i.e., ART failure is less common), the value of more accurate but more costly monitoring strategies, such as VL, is reduced [26]. In Mozambique, 19–24% of patients on 1 st -line ART have evidence of virologic failure [27,28], similar to other settings in sub-Saharan Africa [29,30]; while scale-up of ART coverage continues, investment in longitudinal care is essential to maintain virologic suppression, gain long-term benefits of ART, and reduce transmissions and deaths.…”