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Publication Details
AFRICAN RESEARCH NEXUS
SHINING A SPOTLIGHT ON AFRICAN RESEARCH
Initiating antiretroviral therapy when presenting with higher CD4 cell counts results in reduced loss to follow-up in a resource-limited setting
AIDS, Volume 27, No. 4, Year 2013
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Description
OBJECTIVE: In August 2011, South Africa expanded its adult antiretroviral therapy (ART) guidelines to allow treatment initiation at CD4 cell values 350cells/μl or less. Mortality and morbidity are known to be reduced when initiating at higher CD4 levels; we explored the impact on patient loss to follow-up. DESIGN: An observational cohort study. METHODS: We analyzed routine data of 1430 adult patients initiating ART from April to December 2010 from a Johannesburg primary healthcare clinic offering ART initiation at CD4 cell count 350cells/μl or less since 2010. We compared loss to follow-up (≥3 months late for the last scheduled visit), death, and incident tuberculosis within 1 year of ART initiation for those initiating at CD4 cell values 200 or less versus 201-350cells/μl. RESULTS: Half (52.0%) of patients presented in the lower CD4 cell group [≤200cells/μl, median: 105cells/μl, interquartile range (IQR): 55-154] and initiated ART, and 48.0% in the higher group (CD4 cell count 201-350cells/μl, median: 268cells/μl, IQR: 239-307). The proportion of women and pregnant women was greater in the high CD4 cell group; the lower CD4 cell group included more patients with prevalent tuberculosis. Among men and nonpregnant women, initiating at 201-350cells/μl was associated with 26-42% reduced loss to follow-up compared to those initiating 200cells/μl or less. We found no CD4 cell effect among pregnant women. Risk of mortality [adjusted hazard ratio (aHR) 0.34, 95% confidence interval (CI) 0.13-0.84] and incident tuberculosis (aHR 0.44, 95% CI 0.23-0.85) was lower among the higher CD4 cell group. CONCLUSION: This is one of the first studies from a routine clinical setting to demonstrate South Africa's 2011 expansion of ART treatment guidelines can be enacted without increasing program attrition. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Authors & Co-Authors
Clouse, Kate A.M.
South Africa, Johannesburg
University of the Witwatersrand
United States, Chapel Hill
The University of North Carolina at Chapel Hill
Pettifor, Audrey E.
United States, Chapel Hill
The University of North Carolina at Chapel Hill
Maskew, Mhairi
South Africa, Johannesburg
University of the Witwatersrand
Bassett, Jean
South Africa, Johannesburg
Witkoppen Health and Welfare Centre
van Rie, Annelies
United States, Chapel Hill
The University of North Carolina at Chapel Hill
Gay, Cynthia L.
United States, Chapel Hill
Unc School of Medicine
Behets, Frieda M.T.F.
United States, Chapel Hill
The University of North Carolina at Chapel Hill
Sanne, Ian
South Africa, Johannesburg
University of the Witwatersrand
Fox, Matthew P.
South Africa, Johannesburg
University of the Witwatersrand
United States, Boston
School of Public Health
Statistics
Citations: 53
Authors: 9
Affiliations: 5
Identifiers
Doi:
10.1097/QAD.0b013e32835c12f9
e-ISSN:
14735571
Research Areas
Environmental
Health System And Policy
Study Design
Cohort Study
Study Approach
Quantitative
Study Locations
South Africa
Participants Gender
Male
Female