Original articles

Differences in access and patient outcomes across antiretroviral treatment clinics in the Free State province: A prospective cohort study

Suzanne M Ingle, Margaret May, Kerry Uebel, Venessa Timmerman, Eduan Kotze, Max Bachmann, Jonathan A C Sterne, Matthias Egger, Lara Fairall, for IeDEA- Southern Africa


Objective. To assess differences in access to antiretroviral treatment (ART) and patient outcomes across public sector treatment facilities in the Free State province, South Africa.

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.

Authors' affiliations

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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Cite this article

South African Medical Journal 2010;100(10):675-681.

Article History

Date submitted: 2010-01-21
Date published: 2010-10-01

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