Rapid scaling-up of antiretroviral therapy in 10,000 adults in Côte d'Ivoire: 2-year outcomes and determinants

Abstract

Objective: To assess the rates and determinants of mortality, loss to follow-up and immunological failure in a nongovernmental organization-implemented program of access to antiretroviral treatment in Côte d'Ivoire.

Methods: In each new treatment center, professionals were trained in HIV care, and a computerized data system was implemented. Individual patient and program level determinants of survival, loss to follow-up and immunological failure were assessed by multivariate analysis.

Results: Between May 2004 and February 2007, 10,211 patients started antiretroviral treatment in 19 clinics (median preantiretroviral treatment CD4 cell count, 123 cells/microl; initial regimen zidovudine-lamivudine-efavirenz, 20%; stavudine-lamivudine-efavirenz, 22%; stavudine-lamivudine-nevirapine, 52%). At 18 months on antiretroviral treatment, the median gain in CD4 cell count was +202 cells/microl, the probability of death was 0.15 and the probability of being loss to follow-up was 0.21. In addition to the commonly reported determinants of impaired outcomes (low CD4 cell count, low BMI, low hemoglobin, advanced clinical stage, old age and poor adherence), two factors were also shown to independently jeopardize prognosis: male sex (men vs. women: hazard ratio = 1.52 for death, 1.27 for loss to follow-up, 1.31 for immunological failure); and attending a recently opened clinic (inexperienced vs. experienced centers: hazard ratio = 1.40 for death, 1.58 for loss to follow-up). None of the three outcomes was associated with the drug regimen.

Discussion: In this rapidly scaling-up program, survival and immune reconstitution were good; women and patients followed up in centers with longer experience had better outcomes; outcomes were similar in zidovudine/stavudine-based regimens and in efavirenz/nevirapine-based regimens. Decreasing the rate of loss to follow-up should now be the top priority in antiretroviral treatment rollout.

Figure 1

Flow diagram of enrollment and retention, Study closing date: February 1^st 2007 Lost-to follow-up: patients not known to be dead or transferred out and whose last contact with the care centre was ≥ 3 months (patients who ever started ART) or ≥ 6 months (patients who never started ART) on study closing date. ART: antiretroviral therapy

Figure 2

Figure 2A. Number of patients who started ART over time, by initial ART regimen. ZDV: zidovudine d4T: stavudine EFV: efavirenz ART: antiretroviral therapy Figure 2B. On-ART patients status at the end of each month between the date when the program was launched and the study closing date. Late: patients who where late renewing their supply of ARV drugs but who were not considered as lost-to-follow-up. Lost to follow-up: patients whose last contact with the care centre was ≥ 3 months and who were not known to be dead or transferred out. ART: antiretroviral therapy

Figure 2

Figure 2A. Number of patients who started ART over time, by initial ART regimen. ZDV: zidovudine d4T: stavudine EFV: efavirenz ART: antiretroviral therapy Figure 2B. On-ART patients status at the end of each month between the date when the program was launched and the study closing date. Late: patients who where late renewing their supply of ARV drugs but who were not considered as lost-to-follow-up. Lost to follow-up: patients whose last contact with the care centre was ≥ 3 months and who were not known to be dead or transferred out. ART: antiretroviral therapy

Figure 3

Figure 3A. Survival after ART initiation, by pre-ART CD4 count. CI: confidence interval Figure 3B. Probability of being lost to follow-up after ART initiation, by type of care centre. Lost to follow-up: patients whose last contact with the care centre was ≥ 3 months and who were not known to be dead or transferred out. CI: confidence interval

Figure 3

Figure 3A. Survival after ART initiation, by pre-ART CD4 count. CI: confidence interval Figure 3B. Probability of being lost to follow-up after ART initiation, by type of care centre. Lost to follow-up: patients whose last contact with the care centre was ≥ 3 months and who were not known to be dead or transferred out. CI: confidence interval