Better Antiretroviral Therapy Outcomes at Primary Healthcare Facilities: An Evaluation of Three Tiers of ART Services in Four South African Provinces

Geoffrey Fatti,Peter Bock,Ashraf Grimwood,Cesar Augusto Ugarte-Gil

doi:10.1371/journal.pone.0012888

Geoffrey Fatti, Peter Bock + Show 2 more

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https://doi.org/10.1371/journal.pone.0012888

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Abstract

BackgroundThere are conflicting reports of antiretroviral therapy (ART) effectiveness comparisons between primary healthcare (PHC) facilities and hospitals in low-income settings. This comparison has not been evaluated on a broad scale in South Africa.Methodology/Principal FindingsA retrospective cohort study was conducted including ART-naïve adults from 59 facilities in four provinces in South Africa, enrolled between 2004 and 2007. Kaplan-Meier estimates, competing-risks Cox regression, generalised estimating equation population-averaged models and logistic regression were used to compare death, loss to follow-up (LTFU) and virological suppression (VS) between PHC, district and regional hospitals. 29 203 adults from 47 PHC facilities, nine district hospitals and three regional hospitals were included. Patients at PHC facilities had more advanced WHO stage disease when starting ART. Retention in care was 80.1% (95% CI: 79.3%–80.8%), 71.5% (95% CI: 69.1%–73.8%) and 68.7% (95% CI: 67.0%–69.7%) at PHC, district and regional hospitals respectively, after 24 months of treatment (P<0.0001). In adjusted regression analyses, LTFU was independently increased at regional hospitals (aHR 2.19; 95% CI: 1.94−2.47) and mortality was independently elevated at district hospitals (aHR 1.60; 95% CI: 1.30−1.99) compared to PHC facilities after 12 months of ART. District and regional hospital patients had independently reduced probabilities of VS, aOR 0.76 (95% CI: 0.59−0.97) and 0.64 (95% CI: 0.56−0.75) respectively compared to PHC facilities over 24 months of treatment.Conclusions/SignificanceART outcomes were superior at PHC facilities, despite PHC patients having more advanced clinical stage disease when starting ART, suggesting that ART can be adequately provided at this level and supporting the South African government's call for rapid up-scaling of ART at the primary level of care. Further prospective research is required to determine the degree to which outcome differences are attributable to either facility level characteristics or patient co-morbidity at hospital level.

Highlights

In 2007 UNAIDS estimated that there were 4.9–6.6 million adults and children living with HIV/AIDS and that 270 000–420 000 people died annually from the disease in South Africa [1]
The aim of this study was to compare baseline characteristics and treatment outcomes between patients managed at different levels in the health system in a large routine patient cohort from four provinces in South Africa, representing over 7% of adults enrolled in public sector antiretroviral therapy (ART) facilities between 2004 and 2007 in the country [14]
The number of patients enrolled at primary healthcare (PHC) facilities, district hospitals and regional hospitals were 19 273 (66%), 2483 (8.5%) and 7447 (25.5%) respectively

Summary

Introduction

In 2007 UNAIDS estimated that there were 4.9–6.6 million adults and children living with HIV/AIDS and that 270 000–420 000 people died annually from the disease in South Africa [1]. The government’s HIV/AIDS budgetary allocation for the corresponding period was well below that required to reach this target [5,6], and at the current rate of ART scale up an estimated 2.16 million people will die from the disease between 2007–2011 in South Africa [7]. There are conflicting reports of antiretroviral therapy (ART) effectiveness comparisons between primary healthcare (PHC) facilities and hospitals in low-income settings. This comparison has not been evaluated on a broad scale in South Africa

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