Abstract
BackgroundDespite widespread availability of antiretroviral therapy (ART) in South Africa, there remains a considerable burden of human immunodeficiency virus (HIV)-related morbidity and mortality.ObjectivesTo describe ART initiation and outcome trends over time, with a focus on clients presenting with advanced HIV-infection, so as to identify interventions to reduce morbidity and mortality.MethodsRoutine TIER.Net data from HIV-infected adults who had a documented baseline CD4 count and were newly initiating ART in Johannesburg or Mopani districts from 2004 to 2017 were analysed. Trends in baseline CD4 count and 5-year mortality were investigated and the population initiating ART with CD4 < 200 cells/mm3 was described.ResultsThe Johannesburg and Mopani data sets comprised 203 131 and 101 814 records, respectively. Although median CD4 count increased over time, the proportion of initiations at CD4 < 200 cells/mm3 in 2017 remained high (Johannesburg 39%, Mopani 35%). Mortality was significantly increased among clients with CD4 < 200 compared to those with higher baseline counts (p < 0.001). Even though mortality among clients with low CD4 declined over time, likely because of improved drug regimens, in 2016–2017 mortality was still significantly increased among these clients (p < 0.001). Delivery of cotrimoxazole prophylaxis to clients with low CD4 declined over time to < 30% in 2017 and was associated with clinical stage. Presentation with CD4 < 200 cells/mm3 was associated with older age, male gender and hospitalisation.ConclusionA concerningly large proportion of South Africans still initiate ART at low CD4 counts. This is associated with increased mortality and requires targeted interventions to improve delivery of prophylactic regimens and early engagement in care.
Highlights
In 2017, there were 6.9 million adults living with human immunodeficiency virus (HIV) in South Africa, of whom 61% were receiving treatment.[1]
Among the remaining 203 168 records, 37 (< 1%) had baseline CD4 counts above 2000 and were excluded, leaving a Johannesburg data set of 203 131 records for analysis
This study of routine TIER.Net data demonstrates an increase in mean and median baseline CD4 counts over time, in line with South African guidelines that have repeatedly raised the CD4 cut-off for antiretroviral therapy (ART) initiation[5,8,9,10] and in agreement with previous findings in South Africa and other countries.[2,16,24,25,26]
Summary
In 2017, there were 6.9 million adults living with human immunodeficiency virus (HIV) in South Africa, of whom 61% were receiving treatment.[1] This equates to 4.2 million adults receiving antiretroviral therapy (ART), forming the largest treatment programme in the world.[1] South Africa’s ART programme has demonstrated successful initiation and management of clients on treatment for over a decade, despite rapid programmatic scale-up over this time,[2] and has achieved near-normal life expectancy for HIV-infected adults with timely ART initiation.[3] The ART programme is an essential component of the third Sustainable Development Goal which aims to ensure healthy lives and end the AIDS epidemic by 2030.4. Despite widespread availability of antiretroviral therapy (ART) in South Africa, there remains a considerable burden of human immunodeficiency virus (HIV)-related morbidity and mortality
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