Abstract
BackgroundClinical, immunologic and virologic outcomes at large HIV/AIDS care clinics in resource poor settings are poorly described beyond the first year of highly active antiretroviral treatment (HAART). We aimed to prospectively evaluate long-term treatment outcomes at a large scale HIV/AIDS care clinic in South Africa.MethodsCohort study of patients initiating HAART between April 1, 2004 and March 13, 2007, and followed up until April 1, 2008 at a public HIV/AIDS care clinic in Johannesburg, South Africa. We performed time to event analysis on key treatment outcomes and program impact parameters including mortality, retention in care, CD4 count gain, virologic success and first line regimen durability.Results7583 HIV-infected patients initiated care and contributed to 161,000 person months follow up. Overall mortality rate was low (2.9 deaths per 100 person years, 95% CI 2.6-3.2), but high in the first three months of HAART (8.4 per 100 person years, 95% CI 7.2-9.9). Long-term on-site retention in care was relatively high (74.4% at 4 years, 95%CI 73.2-75.6). CD4 count was above 200 cells/mm3 after 6 months of treatment in almost all patients. By the fourth year of HAART, the majority (59.6%, 95%CI 57.8-61.4) of patients had at least one first line drug (mainly stavudine) substituted. Women were twice as likely to experience drug substitution (OR 1.97, 95% CI 1.80-2.16). By 6 months of HAART, 90.8% suppressed virus below 400 copies. Among those with initial viral suppression, 9.4% (95% CI 8.5-10.3%) had viral rebound within one year of viral suppression, 16.8% (95% CI 15.5-18.1) within 2 years, and 20.6% (95% CI 18.9-22.4) within 3 years of initial suppression. Only 10% of women and 13% of men initiated second line HAART.ConclusionDespite advanced disease presentation and a very large-scale program, high quality care was achieved as indicated by good long-term clinical, immunologic and virologic outcomes and a low rate of second line HAART initiation. High rates of single drug substitution suggest that the public health approach to HAART could be further improved by the use of a more durable first line regimen.
Highlights
Clinical, immunologic and virologic outcomes at large human immunodeficiency virus (HIV)/AIDS care clinics in resource poor settings are poorly described beyond the first year of highly active antiretroviral treatment (HAART)
With more than five million individuals living with HIV and AIDS, South Africa has the largest population of HIVinfected individuals[1,2]
In this study of a large (> 7,500 patients) and rapidly expanding (> 200 new patients each month since 2004) clinic in Johannesburg, South Africa, we evaluated the outcomes of the first four years of activity (> 160,000 person months follow-up) of a South African Department of Health program by comprehensively assessing five key parameters: mortality, loss to follow-up, CD4 count gain viral suppression, and durability of first line HAART regimen
Summary
Immunologic and virologic outcomes at large HIV/AIDS care clinics in resource poor settings are poorly described beyond the first year of highly active antiretroviral treatment (HAART). We aimed to prospectively evaluate long-term treatment outcomes at a large scale HIV/AIDS care clinic in South Africa. Global access to highly active antiretroviral therapy (HAART) has increased dramatically, but the majority of those in need remain untreated, especially in sub-Saharan Africa. Following the political commitment made to include HAART in the Comprehensive Care, Management and Treatment program of the public health sector from April 2004 onwards, South Africa has the largest number of people receiving HAART in the world[3]. After HAART initiation, patients are scheduled for monthly pharmacy visits, clinical visits at month 4 and every 6 months thereafter, and additional visits whenever needed. Patients more than three months late for a scheduled clinic or pharmacy visit are actively traced (three phone calls and a home visit if needed) to ascertain the reason for loss to follow-up
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