Trends and determinants of survival for over 200 000 patients on antiretroviral treatment in the Botswana National Program

Abstract

Objectives:To determine the incidence and risk factors of mortality for all HIV-infected patients receiving antiretroviral treatment at public and private healthcare facilities in the Botswana National HIV/AIDS Treatment Programme.Design:We studied routinely collected data from 226 030 patients enrolled in the Botswana National HIV/AIDS Treatment Programme from 2002 to 2013.Methods:A person-years (P-Y) approach was used to analyse all-cause mortality and follow-up rates for all HIV-infected individuals with documented antiretroviral therapy initiation dates. Marginal structural modelling was utilized to determine the effect of treatment on survival for those with documented drug regimens. Sensitivity analyses were performed to assess the robustness of our results.Results:Median follow-up time was 37 months (interquartile range 11–75). Mortality was highest during the first 3 months after treatment initiation at 11.79 (95% confidence interval 11.49–12.11) deaths per 100 P-Y, but dropped to 1.01 (95% confidence interval 0.98–1.04) deaths per 100 P-Y after the first year of treatment. Twelve-month mortality declined from 7 to 2% of initiates during 2002–2012. Tenofovir was associated with lower mortality than stavudine and zidovudine.Conclusion:The observed mortality rates have been declining over time; however, mortality in the first year, particularly first 3 months of antiretroviral treatment, remains a distinct problem. This analysis showed lower mortality with regimens containing tenofovir compared with zidovudine and stavudine. CD4+ cell count less than 100 cells/μl, older age and being male were associated with higher odds of mortality.

Accounting for and responding to HIV-associated mortality

“…Reported factors for adult mortality in the Botswana national programme [2] are consistent with other reports, and include severe immune deficiency at start of ART [4], male sex [5,6], older age [7], and receipt of suboptimal (i.e. less potent/tolerable) ART regimens [8,9].…”

“…Deaths among patients lost to follow-up were not ascertained and rates will underestimate the mortality experienced by all patients who started ART. Also, some of the decline in mortality observed in Botswana [2] may be because of declining ascertainment of mortality as the programme expanded and retention in care got worse. Finally, the inverse probability of censoring weights implemented in the regression analysis [2] may perform poorly in the absence of additional information on mortality in patients lost to follow-up [3].…”

“…The evaluation of Botswana's public ART programme published in this issue of AIDS provides a national example of the progress made by almost all high HIV-burden countries in Africa [2]. By the end of 2014, the national programme had started almost 250 000 people on ART, from 3500 in 2002.…”

Minimizing fungal disease deaths will allow the UNAIDS target of reducing annual AIDS deaths below 500 000 by 2020 to be realized

“…Gradual movement towards the 90–90–90 ART target will likely see a further reduction in deaths [18]. Many of those to be treated will have high CD4 counts and are not at risk of an early AIDS death.…”

Advanced Human Immunodeficiency Virus Disease in Botswana Following Successful Antiretroviral Therapy Rollout: Incidence of and Temporal Trends in Cryptococcal Meningitis

“…However, the latest Botswana AIDS Indicator Survey data estimated 30% of the population aged 10-64 years had never undergone HIV testing in 2013 and ART coverage [24], at about 250,000 HIV-infected individuals by 2015 [23], needs to expand by 100,000, which will put a strain on existing services [27]. Similar scale-up will likely be even more disruptive throughout the rest of Africa, where the number of people receiving ART needs to double to cover all HIVinfected individuals [28].…”