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Twelve-year mortality in adults initiating antiretroviral therapy in South Africa

Introduction: South Africa has the largest number of individuals living with HIV and the largest antiretroviral therapy (ART) programme worldwide. In September 2016, ART eligibility was extended to all 7.1 million HIV-positive South Africans. To ensure that further expansion of services does not com...

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Autores principales: Cornell, Morna, Johnson, Leigh F., Wood, Robin, Tanser, Frank, Fox, Matthew P., Prozesky, Hans, Schomaker, Michael, Egger, Matthias, Davies, Mary-Ann, Boulle, Andrew
Formato: Online Artículo Texto
Lenguaje:English
Publicado: Taylor & Francis 2017
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640314/
https://www.ncbi.nlm.nih.gov/pubmed/28953328
http://dx.doi.org/10.7448/IAS.20.1.21902
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author Cornell, Morna
Johnson, Leigh F.
Wood, Robin
Tanser, Frank
Fox, Matthew P.
Prozesky, Hans
Schomaker, Michael
Egger, Matthias
Davies, Mary-Ann
Boulle, Andrew
author_facet Cornell, Morna
Johnson, Leigh F.
Wood, Robin
Tanser, Frank
Fox, Matthew P.
Prozesky, Hans
Schomaker, Michael
Egger, Matthias
Davies, Mary-Ann
Boulle, Andrew
author_sort Cornell, Morna
collection PubMed
description Introduction: South Africa has the largest number of individuals living with HIV and the largest antiretroviral therapy (ART) programme worldwide. In September 2016, ART eligibility was extended to all 7.1 million HIV-positive South Africans. To ensure that further expansion of services does not compromise quality of care, long-term outcomes must be monitored. Few studies have reported long-term mortality in resource-constrained settings, where mortality ascertainment is challenging. Combining site records with data linked to the national vital registration system, sites in the International Epidemiology Databases to Evaluate AIDS Southern Africa collaboration can identify >95% of deaths in patients with civil identification numbers (IDs). This study used linked data to explore long-term mortality and viral suppression among adults starting ART in South Africa. Methods: The study was a cohort analysis of routine data on adults with IDs starting ART 2004–2015 in five large ART cohorts. Mortality was estimated overall and by gender using the Kaplan-Meier estimator and Cox’s proportional hazards regression. Standardized mortality ratios (SMRs) were calculated by dividing observed numbers of deaths by numbers expected if patients had been HIV-negative. Viral suppression in patients with viral loads (VLs) in their last year of follow-up was the secondary outcome. Results: Among 72,812 adults followed for 350,376 person years (pyrs), the crude mortality rate was 3.08 (95% CI 3.02–3.14)/100 pyrs. Patients were predominantly female (67%) and the percentage of men initiating ART did not increase. Cumulative mortality 12 years after ART initiation was 23.9% (33.4% male and 19.4% female). Mortality peaked in patients enrolling in 2007–2009 and was higher in men than women at all durations. Observed mortality rates were higher than HIV-negative mortality, decreasing with duration. By 48 months, observed mortality was close to that in the HIV-negative population, and SMRs were similar for all baseline CD4 strata. Three-quarters of patients had VLs in their last year, and 86% of these were virally suppressed. Conclusions: The South African ART programme has shown a remarkable ability to initiate and manage patients successfully over 12 years, despite rapid expansion. With further scale-up, testing and initiating men on ART must be a national priority.
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spelling pubmed-56403142017-10-23 Twelve-year mortality in adults initiating antiretroviral therapy in South Africa Cornell, Morna Johnson, Leigh F. Wood, Robin Tanser, Frank Fox, Matthew P. Prozesky, Hans Schomaker, Michael Egger, Matthias Davies, Mary-Ann Boulle, Andrew J Int AIDS Soc Research Article Introduction: South Africa has the largest number of individuals living with HIV and the largest antiretroviral therapy (ART) programme worldwide. In September 2016, ART eligibility was extended to all 7.1 million HIV-positive South Africans. To ensure that further expansion of services does not compromise quality of care, long-term outcomes must be monitored. Few studies have reported long-term mortality in resource-constrained settings, where mortality ascertainment is challenging. Combining site records with data linked to the national vital registration system, sites in the International Epidemiology Databases to Evaluate AIDS Southern Africa collaboration can identify >95% of deaths in patients with civil identification numbers (IDs). This study used linked data to explore long-term mortality and viral suppression among adults starting ART in South Africa. Methods: The study was a cohort analysis of routine data on adults with IDs starting ART 2004–2015 in five large ART cohorts. Mortality was estimated overall and by gender using the Kaplan-Meier estimator and Cox’s proportional hazards regression. Standardized mortality ratios (SMRs) were calculated by dividing observed numbers of deaths by numbers expected if patients had been HIV-negative. Viral suppression in patients with viral loads (VLs) in their last year of follow-up was the secondary outcome. Results: Among 72,812 adults followed for 350,376 person years (pyrs), the crude mortality rate was 3.08 (95% CI 3.02–3.14)/100 pyrs. Patients were predominantly female (67%) and the percentage of men initiating ART did not increase. Cumulative mortality 12 years after ART initiation was 23.9% (33.4% male and 19.4% female). Mortality peaked in patients enrolling in 2007–2009 and was higher in men than women at all durations. Observed mortality rates were higher than HIV-negative mortality, decreasing with duration. By 48 months, observed mortality was close to that in the HIV-negative population, and SMRs were similar for all baseline CD4 strata. Three-quarters of patients had VLs in their last year, and 86% of these were virally suppressed. Conclusions: The South African ART programme has shown a remarkable ability to initiate and manage patients successfully over 12 years, despite rapid expansion. With further scale-up, testing and initiating men on ART must be a national priority. Taylor & Francis 2017-09-25 /pmc/articles/PMC5640314/ /pubmed/28953328 http://dx.doi.org/10.7448/IAS.20.1.21902 Text en © 2017 Cornell M et al; http://creativecommons.org/licenses/by/3.0/ licensee International AIDS Society. This is an Open Access article distributed under the terms of the Creative Commons Attribution 3.0 Unported (CC BY 3.0) License (http://creativecommons.org/licenses/by/3.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Research Article
Cornell, Morna
Johnson, Leigh F.
Wood, Robin
Tanser, Frank
Fox, Matthew P.
Prozesky, Hans
Schomaker, Michael
Egger, Matthias
Davies, Mary-Ann
Boulle, Andrew
Twelve-year mortality in adults initiating antiretroviral therapy in South Africa
title Twelve-year mortality in adults initiating antiretroviral therapy in South Africa
title_full Twelve-year mortality in adults initiating antiretroviral therapy in South Africa
title_fullStr Twelve-year mortality in adults initiating antiretroviral therapy in South Africa
title_full_unstemmed Twelve-year mortality in adults initiating antiretroviral therapy in South Africa
title_short Twelve-year mortality in adults initiating antiretroviral therapy in South Africa
title_sort twelve-year mortality in adults initiating antiretroviral therapy in south africa
topic Research Article
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5640314/
https://www.ncbi.nlm.nih.gov/pubmed/28953328
http://dx.doi.org/10.7448/IAS.20.1.21902
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