Outcomes of Antiretroviral Treatment Programs in Rural Southern Africa

Abstract

Background Data on outcomes of antiretroviral treatment (ART) programs in rural sub-Saharan African are scarce. We describe early losses and long-term outcomes in six rural programs in Southern Africa with limited access to viral load monitoring and second-line ART. Methods Patients aged ≥16 years starting ART in two programs each in Zimbabwe, Mozambique and Lesotho were included. We evaluated risk factors for no follow-up after starting ART and mortality and loss to follow-up (LTFU) over 3 years of ART, using logistic regression and competing risk models. Odds ratios and sub-distribution hazard ratios, adjusted for gender, age category, CD4 category and WHO stage at start of ART are reported. Results Among 7,725 patients, 449 (5.8%) did not return after initiation of ART. Over 9,575 person-years, 698 (9.6%) of those with at least one follow-up visit died and 1,319 (18.1%) were LTFU. At 3 years the cumulative incidence of death and LTFU were 12.5% (11.5–13.5%) and 25.4% (24.0–26.9%), respectively, with important differences between countries: in Zimbabwe 75.1% (72.8–77.3%) were alive and on ART at 3 years compared to 55.4% (52.8–58.0%) in Lesotho and 51.6% (48.0–55.2%) in Mozambique. In all settings young age and male gender predicted LTFU, whereas advanced clinical stage and low baseline CD4 counts predicted death. Conclusions In African ART programs with limited access to second-line treatment, mortality and LTFU are high in the first 3 years of ART. Low retention in care is a major threat to the sustainability of ART delivery in Southern Africa, particularly in rural sites.

Community-Based ART Resulted in Excellent Retention and Can Leverage Community Empowerment in Rural Lesotho, A Mixed Method Study

“…6 Furthermore, one year retention among treatment experienced CAG members at HC Nazareth was excellent (98.7%). Members reported multiple collateral benefits and commented that membership in CAG: 1) reduced time, effort, and money spent to get a monthly ART refill; 2) changed the perception by clinic staff as now they represent a group of patients; 3) induced peer support among fellow members, resulting in reports of improved adherence, home visits when a fellow member was sick, family and socio-economical support, empowerment to deal with stigma, 4) increased the openness with which people can adhere to their treatment; 5) generated interest and promoted health seeking behaviour of other community members, including community leaders; and 6) resulted in a feeling of relief and comfort.…”

“…2 Attrition is problematic; in rural Lesotho 55.4% were reported to be alive and on treatment at three years on ART, 13.5% had died, and 30.9% were lost to follow-up. 6 Scale-up of ART has been hampered by chronic understaffing and inadequate infrastructure in the healthcare system. 7 In 2009, drawing on a care model rolled out in Mozambique, 8,9 the Lesotho Ministry of Health decided to pilot Community ART Groups (CAG).…”

Temporal Trends in Treatment Outcomes for HIV-1 and HIV-2-Infected Adults Enrolled in Côte d'Ivoire's National Antiretroviral Therapy Program

“…Stacked cumulative incidence curves were used to illustrate cumulative probability of death and LTFU over time for each annual cohort of adults starting ART [33].…”

SMSaúde: Evaluating Mobile Phone Text Reminders to Improve Retention in HIV Care for Patients on Antiretroviral Therapy in Mozambique

“…2 Despite various interventions to improve patient adherence and retention in HIV care in Mozambique, the number of patients who discontinue treatment is still increasing. 1,3 For patients on ART, reduced loss to follow-up has important correlations with better clinical outcomes, including weight gain, recovery of CD4 count, reduction of viral load, and a lower likelihood of resistance, morbidity, and mortality. 2–5 In addition, studies have also shown that access to HIV care, initiation of ART and optimal adherence decreases the risk of sexually transmitting HIV.…”