Inventi Impact: Preventive & Social Medicines

Inventi:hpsm/20734/16

Determinants of Time to Antiretroviral Treatment Initiation and Subsequent Mortality on\nTreatment in a Cohort in Rural Northern Malawi

Background: To optimise care HIV patients need to be promptly initiated on antiretroviral therapy (ART) and subsequently\nretained on treatment. In this study we report on the interval between enrolment and treatment initiation,\nand investigate subsequent attrition and mortality of patients on ART at a rural clinic in Malawi.\nMethods: HIV-positive individuals were recruited to a cohort study between January 2008 and August 2011 at\nChilumba Rural Hospital (CRH). Outcomes were ascertained, up to 7 years after enrolment, through follow-up and\nby linkage to ART registers and the Karonga Health and Demographic Surveillance System (KHDSS). Kaplanââ?¬â??Meier\nmethods and Cox regression were used to examine ART initiation after enrolment, mortality after ART initiation, and\nattrition after ART initiation.\nResults: Of the 617 individuals recruited, 523 initiated ART between January 2008 and January 2015. Median time\nfrom HIV testing to commencement of ART was 59 days (IQR: 10ââ?¬â??330). By a year after enrolment 74.2 % (95 % CI\n70.6ââ?¬â??77.7 %) had initiated ART. Baseline clinical data at ART initiation and data on attrition was only available for the\n438 individuals who initiated ART during active follow-up, between January 2008 and August 2011. Of these individuals,\n6 were missing Ministry of Health numbers, leaving 432 included in analyses of attrition and mortality. At 4 years\nafter ART initiation 71.3 % (95 % CI 65.7ââ?¬â??76.2 %) of these patients were retained on treatment at the CRH and 17.2 %\n(95 % CI 13.8ââ?¬â??21.4 %) had died. Participants who had a lower CD4 count at enrolment (ââ?°Â¤350 cells/Ã?¼l), enrolled in\n2008, or tested for HIV at the CRH rather than through serosurveys, initiated treatment faster. Once on treatment,\nmortality rates were higher in patients who were HIV tested at the CRH, male, older (ââ?°Â¥35 years), missing a CD4 count,\nor underweight (BMI < 18.5) at ART initiation.\nConclusions: Through linkage to the KHDSS and ART registers it was possible to continue follow-up beyond the end\nof the initial cohort study. Annual mortality after ART initiation remained considerable over a period of 4 years. Greater\naccess to HIV and CD4 testing alongside initiation at higher CD4 counts, as planned in the test and treat strategy,\ncould reduce this mortality.