Differences in access and patient outcomes across antiretroviral treatment clinics in the Free State province: A prospective cohort study
Design. Prospective cohort study with retrospective database linkage. We analysed data on patients enrolled in the treatment programme across 36 facilities between May 2004 and December 2007, and assessed percentage initiating ART and percentage dead at 1 year after enrolment. Multivariable logistic regression was used to estimate associations of facility-level and patient-level characteristics with both mortality and treatment status.
Results. Of 44 866 patients enrolled, 15 219 initiated treatment within 1 year; 8 778 died within 1 year, 7 286 before accessing ART. Outcomes at 1 year varied greatly across facilities and more variability was explained by facility-level factors than by patient-level factors. The odds of starting treatment within 1 year improved over calendar time. Patients enrolled in facilities with treatment initiation available on site had higher odds of starting treatment and lower odds of death at 1 year compared with those enrolled in facilities that did not offer treatment initiation. Patients were less likely to start treatment if they were male, severely immunosuppressed (CD4 count ≤50 cells/µl), or underweight (<50 kg). Men were also more likely to die in the first year after enrolment.
Conclusions. Although increasing numbers of patients started ART between 2004 and 2007, many patients died before accessing ART. Patient outcomes could be improved by decentralisation of treatment services, fast-tracking the most immunodeficient patients and improving access, especially for men.
Suzanne M Ingle, Department of Social Medicine, University of Bristol
Margaret May, Department of Social Medicine, University of Bristol
Kerry Uebel, University of Cape Town Lung Institute, University of Cape Town
Venessa Timmerman, University of Cape Town Lung Institute, University of Cape Town
Eduan Kotze, Free State Department of Health, Bloemfontein
Max Bachmann, Health Services Research, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich
Jonathan A C Sterne, Department of Social Medicine, University of Bristol
Matthias Egger, University of Bern
Lara Fairall, University of Cape Town Lung Institute, University of Cape Town
for IeDEA- Southern Africa,
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Date published: 2010-10-01
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