PMID- 29136014
DCOM- 20171204
LR  - 20180130
IS  - 1549-1676 (Electronic)
IS  - 1549-1277 (Linking)
VI  - 14
IP  - 11
DP  - 2017 Nov
TI  - Treatment guidelines and early loss from care for people living with HIV in Cape 
      Town, South Africa: A retrospective cohort study.
PG  - e1002434
LID - 10.1371/journal.pmed.1002434 [doi]
AB  - BACKGROUND: South Africa has undergone multiple expansions in antiretroviral
      therapy (ART) eligibility from an initial CD4+ threshold of </=200 cells/mul to
      providing ART for all people living with HIV (PLWH) as of September 2016. We
      evaluated the association of programmatic changes in ART eligibility with loss
      from care, both prior to ART initiation and within the first 16 weeks of starting
      treatment, during a period of programmatic expansion to ART treatment at CD4+ </=
      350 cells/mul. METHODS AND FINDINGS: We performed a retrospective cohort study of
      4,025 treatment-eligible, non-pregnant PLWH accessing care in a community health 
      center in Gugulethu Township affiliated with the Desmond Tutu HIV Centre in Cape 
      Town. The median age of participants was 34 years (IQR 28-41 years), almost 62%
      were female, and the median CD4+ count was 173 cells/mul (IQR 92-254 cells/mul). 
      Participants were stratified into 2 cohorts: an early cohort, enrolled into care 
      at the health center from 1 January 2009 to 31 August 2011, when guidelines
      mandated that ART initiation required CD4+ </= 200 cells/mul, pregnancy, advanced
      clinical symptoms (World Health Organization [WHO] stage 4), or comorbidity
      (active tuberculosis); and a later cohort, enrolled into care from 1 September
      2011 to 31 December 2013, when the treatment threshold had been expanded to CD4+ 
      </= 350 cells/mul. Demographic and clinical factors were compared before and
      after the policy change using chi-squared tests to identify potentially
      confounding covariates, and logistic regression models were used to estimate the 
      risk of pre-treatment (pre-ART) loss from care and early loss within the first 16
      weeks on treatment, adjusting for age, baseline CD4+, and WHO stage. Compared
      with participants in the later cohort, participants in the earlier cohort had
      significantly more advanced disease: median CD4+ 146 cells/mul versus 214
      cells/mul (p < 0.001), 61.1% WHO stage 3/4 disease versus 42.8% (p < 0.001), and 
      pre-ART mortality of 34.2% versus 16.7% (p < 0.001). In total, 385 ART-eligible
      PLWH (9.6%) failed to initiate ART, of whom 25.7% died before ever starting
      treatment. Of the 3,640 people who started treatment, 58 (1.6%) died within the
      first 16 weeks in care, and an additional 644 (17.7%) were lost from care within 
      16 weeks of starting ART. PLWH who did start treatment in the later cohort were
      significantly more likely to discontinue care in <16 weeks (19.8% versus 15.8%, p
      = 0.002). After controlling for baseline CD4+, WHO stage, and age, this effect
      remained significant (adjusted odds ratio [aOR] = 1.30, 95% CI 1.09-1.55). As
      such, it remains unclear if early attrition from care was due to a "healthy
      cohort" effect or to overcrowding as programs expanded to accommodate the broader
      guidelines for treatment. Our findings were limited by a lack of generalizability
      (given that these data were from a single high-volume site where testing and
      treatment were available) and an inability to formally investigate the effect of 
      crowding on the main outcome. CONCLUSIONS: Over one-quarter of this ART-eligible 
      cohort did not achieve the long-term benefits of treatment due to early
      mortality, ART non-initiation, or early ART discontinuation. Those who started
      treatment in the later cohort appeared to be more likely to discontinue care
      early, and this outcome appeared to be independent of CD4+ count or WHO stage.
      Future interventions should focus on those most at risk for early loss from care 
      as programs continue to expand in South Africa.
FAU - Katz, Ingrid T
AU  - Katz IT
AD  - Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts,
      United States of America.
AD  - Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, 
      United States of America.
AD  - Harvard Medical School, Boston, Massachusetts, United States of America.
FAU - Kaplan, Richard
AU  - Kaplan R
AD  - Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South
FAU - Fitzmaurice, Garrett
AU  - Fitzmaurice G
AD  - Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston,
      Massachusetts, United States of America.
AD  - Laboratory for Psychiatric Biostatistics, McLean Hospital, Belmont,
      Massachusetts, United States of America.
FAU - Leone, Dominick
AU  - Leone D
AD  - Ragon Institute of MGH, MIT and Harvard, Boston, Massachusetts, United States of 
FAU - Bangsberg, David R
AU  - Bangsberg DR
AD  - Oregon Health & Science University-Portland State University School of Public
      Health, Portland, Oregon, United States of America.
FAU - Bekker, Linda-Gail
AU  - Bekker LG
AD  - Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South
FAU - Orrell, Catherine
AU  - Orrell C
AD  - Desmond Tutu HIV Centre, University of Cape Town Medical School, Cape Town, South
LA  - eng
GR  - K23 MH097667/MH/NIMH NIH HHS/United States
PT  - Journal Article
PT  - Observational Study
DEP - 20171114
PL  - United States
TA  - PLoS Med
JT  - PLoS medicine
JID - 101231360
RN  - 0 (Anti-Retroviral Agents)
SB  - IM
MH  - Adult
MH  - Anti-Retroviral Agents/*therapeutic use
MH  - Antiretroviral Therapy, Highly Active/*mortality/trends
MH  - Cohort Studies
MH  - Community Health Centers/trends
MH  - Female
MH  - HIV Infections/*drug therapy/*mortality
MH  - HIV-1/drug effects
MH  - Humans
MH  - Male
MH  - Patient Care/*mortality/standards/trends
MH  - *Practice Guidelines as Topic/standards
MH  - Retrospective Studies
MH  - South Africa/epidemiology
MH  - Treatment Outcome
PMC - PMC5685472
EDAT- 2017/11/15 06:00
MHDA- 2017/12/05 06:00
CRDT- 2017/11/15 06:00
PHST- 2017/06/09 00:00 [received]
PHST- 2017/10/10 00:00 [accepted]
PHST- 2017/11/15 06:00 [entrez]
PHST- 2017/11/15 06:00 [pubmed]
PHST- 2017/12/05 06:00 [medline]
AID - 10.1371/journal.pmed.1002434 [doi]
AID - PMEDICINE-D-17-02015 [pii]
PST - epublish
SO  - PLoS Med. 2017 Nov 14;14(11):e1002434. doi: 10.1371/journal.pmed.1002434.
      eCollection 2017 Nov.