Men living with HIV in sub-Saharan Africa have sub-optimal engagement in antiretroviral therapy (ART) Programs. Generic ART counselling curriculum in Malawi does not meet men’s needs and should be tailored to men.We developed a... more
Men living with HIV in sub-Saharan Africa have sub-optimal engagement in antiretroviral therapy (ART) Programs. Generic ART counselling curriculum in Malawi does not meet men’s needs and should be tailored to men.We developed a male-specific ART counselling curriculum, adapted from the Malawi Ministry of Health (MOH) curriculum based on literature review of men’s needs and motivations for treatment. The curriculum was piloted through group counselling with men in 6 communities in Malawi, with focus group discussion (FGD) conducted immediately afterward (n=85 men) to assess knowledge of ART, motivators and barriers to care, and perceptions of the male-specific curriculum. Data were analysed in Atlas.ti using grounded theory. We conducted a half-day meeting with MOH and partner stakeholders to finalize the curriculum (n=5).The male-specific curriculum adapted three existing topics from generic counselling curriculum (status disclosure, treatment as prevention, and ART side effects) an...
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ObjectivesMen in sub‐Saharan Africa (SSA) have lower rates of antiretroviral therapy (ART) initiation and higher rates of early default than women. Little is known about effective interventions to improve men's outcomes. We conducted... more
ObjectivesMen in sub‐Saharan Africa (SSA) have lower rates of antiretroviral therapy (ART) initiation and higher rates of early default than women. Little is known about effective interventions to improve men's outcomes. We conducted a scoping review of interventions aimed to increase ART initiation and/or early retention among men in SSA since universal treatment policies were implemented.MethodsThree databases, HIV conference databases and grey literature were searched for studies published between January 2016 to May 2021 that reported on initiation and/or early retention among men. Eligibility criteria included: participants in SSA, data collected after universal treatment policies were implemented (2016–2021), quantitative data on ART initiation and/or early retention for males, general male population (not exclusively focused on key populations), intervention study (report outcomes for at least one non‐standard service delivery strategy), and written in English.ResultsOf t...
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ImportancePeople with mental illness have a reduced life expectancy, but the extent of the mortality gap and the contribution of natural and unnatural causes to excess mortality among people with mental illness in South Africa are... more
ImportancePeople with mental illness have a reduced life expectancy, but the extent of the mortality gap and the contribution of natural and unnatural causes to excess mortality among people with mental illness in South Africa are unknown.ObjectiveTo quantify excess mortality due to natural and unnatural causes associated with mental illness.Design, setting and participantsCohort study using reimbursement claims and vital registration of beneficiaries of a South African medical insurance scheme, aged 15-84 years and covered by medical insurance at any point between January 1, 2011, and June 30, 2020.ExposuresICD-10 diagnoses of mental disorders including organic, substance use, psychotic, mood, anxiety, eating, personality, and developmental disorders.OutcomesMortality from natural, unnatural, unknown and all causes, as measured by the life-years lost (LYL) metric.ResultsWe followed 1 070 183 beneficiaries (51.7% female, median age 36.1 years for a median duration of 3.0 years, of w...
Research Interests: Psychiatry, Mental Health, Medicine, Mental Illness, Anxiety, and 4 moreMood, Life Expectancy, Cohort, and ANXIETY
Background Men experience twice the mortality of women while on ART in sub-Saharan Africa (SSA) largely due to late HIV diagnosis and poor retention. Here we propose to conduct an individually randomized control trial (RCT) to investigate... more
Background Men experience twice the mortality of women while on ART in sub-Saharan Africa (SSA) largely due to late HIV diagnosis and poor retention. Here we propose to conduct an individually randomized control trial (RCT) to investigate the impact of three-month home-based ART (hbART) on viral suppression among men who were not engaged in care. Methods and Design A programmatic, individually randomized non-blinded, non-inferiority-controlled trial design (ClinicalTrials.orgNCT04858243). Through medical chart reviews we will identify non-engaged men living with HIV, ≥15years of age who are not currently engaged in ART care, including (1) men who have tested HIV-positive and have not initiated ART within 7 days; (2) men who have initiated ART but are at risk of immediate default; and (3) men who have defaulted from ART. With 1:1 computer block randomization to either hbART or facility-based ART (fbART) arms, we will recruit men from 10-15 high-burden health facilities in central and...
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ABSTRACTBackgroundMen are underrepresented in HIV services throughout sub-Saharan Africa. Little is known about health care worker (HCW) perceptions of men as clients, which may directly affect the quality of care provided, and HCWs’... more
ABSTRACTBackgroundMen are underrepresented in HIV services throughout sub-Saharan Africa. Little is known about health care worker (HCW) perceptions of men as clients, which may directly affect the quality of care provided, and HCWs’ buy-in for male-specific interventions.MethodsFocus group discussions (FGDs) were conducted in 2016 with HCWs from 15 facilities across Malawi and Mozambique, and were originally conducted to evaluate barriers to universal treatment (not gender or internal bias). FGDs were conducted in local languages, recorded, translated to English, and transcribed. For this study, we focused on HCW perceptions of men as HIV clients, using inductive and deductive coding in Atlas.ti v.8, and analyzed codes using constant comparison methods.Findings20 FGDs with 154 HCWs working in HIV treatment clinics were included. Median age was 30 years, 59% were female, and 43% were providers versus support staff. HCWs held strong implicit bias against men as clients. Most HCWs bel...
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Background: Antiretroviral therapy program mortality maybe underestimated if deceased patients are misclassified as lost. Methods: We used two-stage inverse probability weighting to account for probability of being: sampled for tracing... more
Background: Antiretroviral therapy program mortality maybe underestimated if deceased patients are misclassified as lost. Methods: We used two-stage inverse probability weighting to account for probability of being: sampled for tracing and found by the tracer. Results: Among 680 children and youth aged <25 years on antiretroviral therapy who were lost and traced in Southern Africa between October 2017 and November 2019, estimated mortality was high at 9.1% (62/680). After adjusting for measured covariates and within-site clustering, mortality remained lower for young adults aged 20–24 years compared with infants aged <2 years [adjusted hazard ratio: 0.40 (95% confidence interval: 0.31 to 0.51)]. Conclusions: Our study confirms high unreported mortality in children and youth who are lost and the need for tracing to assess vital status among those who are lost to accurately report on program mortality.
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Men have higher rates of attrition from antiretroviral therapy (ART) programs than women. In Khayelitsha, a high HIV prevalence area in South Africa, two public sector primary healthcare clinics offer services, including HIV testing and... more
Men have higher rates of attrition from antiretroviral therapy (ART) programs than women. In Khayelitsha, a high HIV prevalence area in South Africa, two public sector primary healthcare clinics offer services, including HIV testing and treatment, exclusively to men. We compared attrition from ART care among men initiating ART at these clinics with male attrition in six general primary healthcare clinics in Khayelitsha. We described baseline characteristics of patients initiating ART at the male and general clinics from 1 January 2014 to 31 March 2018. We used exposure propensity scores (generated based on baseline health and age) to match male clinic patients 1:1 to males at other clinics. The association between attrition (death or loss to follow-up, defined as no visits for nine months) and clinic type was estimated using Cox proportional hazards regression. Follow-up time began at ART initiation and ended at attrition, clinic transfer, or dataset closure. Before matching, patien...
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AimsIn March 2020, South Africa introduced a lockdown in response to the COVID-19 pandemic, entailing the suspension of all non-essential activities and a complete ban of tobacco and alcohol sales. We studied the effect of the lockdown on... more
AimsIn March 2020, South Africa introduced a lockdown in response to the COVID-19 pandemic, entailing the suspension of all non-essential activities and a complete ban of tobacco and alcohol sales. We studied the effect of the lockdown on mental health care utilisation rates in private-sector care in South Africa.MethodsWe did an interrupted time series analysis using insurance claims from January 1, 2017, to June 1, 2020 of beneficiaries 18 years or older from a large private sector medical aid scheme. We calculated weekly outpatient consultation and hospital admission rates for organic mental disorders, substance use disorders, serious mental disorders, depression, anxiety, other mental disorders, any mental disorder, and alcohol withdrawal syndrome. We calculated adjusted odds ratios (OR) for the effect of the lockdown on weekly outpatient consultation and hospital admission rates and the weekly change in rates during the lockdown until June 1, 2020.Results710,367 persons were fo...
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Research Interests: Medicine and Dolutegravir
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Aims Mental disorders are common in people living with HIV (PLWH) but often remain untreated. This study aimed to explore the treatment gap for mental disorders in adults followed-up in antiretroviral therapy (ART) programmes in South... more
Aims Mental disorders are common in people living with HIV (PLWH) but often remain untreated. This study aimed to explore the treatment gap for mental disorders in adults followed-up in antiretroviral therapy (ART) programmes in South Africa and disparities between ART programmes regarding the provision of mental health services. Methods We conducted a cohort study using ART programme data and linked pharmacy and hospitalisation data to examine the 12-month prevalence of treatment for mental disorders and factors associated with the rate of treatment for mental disorders among adults, aged 15–49 years, followed-up from 1 January 2012 to 31 December 2017 at one private care, one public tertiary care and two pubic primary care ART programmes in South Africa. We calculated the treatment gap for mental disorders as the discrepancy between the 12-month prevalence of mental disorders in PLWH (aged 15–49 years) in South Africa (estimated based on data from the Global Burden of Disease stud...
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Background Community-based, mobile HIV counselling and testing (HCT) and screening for non-communicable diseases (NCDs) may improve early diagnosis and referral for care in underserved populations. We evaluated HCT/NCD data and described... more
Background Community-based, mobile HIV counselling and testing (HCT) and screening for non-communicable diseases (NCDs) may improve early diagnosis and referral for care in underserved populations. We evaluated HCT/NCD data and described population characteristics of those visiting a mobile clinic in high HIV disease burden settings in Cape Town, South Africa, between 2008 and 2016. Methods Trained counsellors registered patients ≥12 years old at a mobile clinic, which offered HCT and blood pressure, diabetes (glucose testing) and obesity (body mass index) screening. A nurse referred patients who required HIV treatment or NCD care. Using multivariable logistic regression, we estimated correlates of new HIV diagnoses adjusting for gender, age and year. Results Overall, 43,938 individuals (50% male; 29% <25 years; median age = 31 years) tested for HIV at the mobile clinic, where 27% of patients (66% of males, 34% of females) reported being debut HIV testers. Males not previously te...
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The data set contains HCT/NCD data describing population characteristics of those visiting a mobile clinic in Cape Town, SA, between 2008 and 2016. <br> <b>The aim of this research was to evaluate mobile clinic data... more
The data set contains HCT/NCD data describing population characteristics of those visiting a mobile clinic in Cape Town, SA, between 2008 and 2016. <br> <b>The aim of this research was to evaluate mobile clinic data </b>and describe population characteristics of those visiting a mobile clinic offering integrated chronic disease screening in high HIV disease burden, limited-resource settings in the Cape Town, South Africa, between 2008 and 2016.<br>Mobile HIV testing services can reach people who delay visiting conventional clinic facilities, including men living with HIV not previously tested. Over half of those previously diagnosed HIV positive were not yet on treatment. This gap requires urgent intervention to provide accessible and desirable treatment options.
Globally, an estimated 3.4 million children are living with HIV, yet little is known about the effects of HIV and antiretroviral treatment (ART) on the developing brain, and the neurodevelopmental and behavioural outcomes of perinatally... more
Globally, an estimated 3.4 million children are living with HIV, yet little is known about the effects of HIV and antiretroviral treatment (ART) on the developing brain, and the neurodevelopmental and behavioural outcomes of perinatally HIV-infected (PHIV) adolescents. We reviewed the literature on neurodevelopmental outcomes in PHIV children and adolescents, and summarized the current evidence on behaviour, general cognition, specific domains, hearing and language, school performance and physical disabilities due to neurological problems. Evidence suggests that PHIV children do not perform as well as controls on general cognitive tests, processing speed and visualspatial tasks, and are at much higher risk for psychiatric and mental health problems. Children with AIDS-defining diagnoses are particularly at risk for poorer outcomes. A striking finding is the lack of published data specific to the adolescent age group (1025 years), particularly from resource-constrained countries, whi...
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Research Interests: Global Health, Medicine, HIV, Humans, Female, and 13 moreMale, Clinical Sciences, Adult, Public health systems and services research, Time Factors, HIV Care, World Health Organization, Medicine and Health Sciences, Surveys and Questionnaires, Delivery of Health Care, Health facilities, antiretroviral treatment, and HIV infections
Globally and in South African specifically, men account for 56% and 62% of all tuberculosis (TB) cases, respectively. Men are at increased risk of not accessing TB testing or treatment, and having poor treatment outcomes. Unfortunately,... more
Globally and in South African specifically, men account for 56% and 62% of all tuberculosis (TB) cases, respectively. Men are at increased risk of not accessing TB testing or treatment, and having poor treatment outcomes. Unfortunately, no interventions exist to address these issues. Toward the development of targeted, patient-centered TB care and support interventions, we used semistructured interviews to explored men’s social network composition, TB testing behaviors, disclosure and treatment support, clinical experiences, and TB’s influence on daily living. Data were analyzed using a thematic approach guided by the Network Individual Resource Model to identify mental and tangible resources influential and preferred during engagement in TB treatment. Men emphasized the desire for peer-to-peer support to navigate TB-related stigma and unhealthy masculinity norms. Men advocated for awareness events to educate communities about their challenges with TB. Men strongly suggested that in...
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To the Editors: We welcome the publication by Fox and Rosen updating estimates of retention of adult antiretroviral therapy (ART) patients in lowand middleincome countries. Given that the benefits of ART to both patients and the community... more
To the Editors: We welcome the publication by Fox and Rosen updating estimates of retention of adult antiretroviral therapy (ART) patients in lowand middleincome countries. Given that the benefits of ART to both patients and the community are dependent on patients being retained and adherent to treatment, improving our understanding of retention is essential. In response to the authors’ previous reviews, methodological concerns were raised. In this updated version, the authors acknowledge the methodological limitation of combining data with varying definitions of loss to follow-up. However, their conclusion of a chronological trend of increasing patient attrition in recent years should be presented with a caveat. Increasingly, we understand that patients on lifelong ART may have periods of treatment interruptions or transient interruptions in care. Therefore, interpreting the higher rates of attrition in more recent cohorts may be true or, as recent modeling suggests, could partly be an artefact of the bias from these interruptions, which affect recently enrolled patients more strongly because they have had less time to return to care. This updated review also draws attention to the scarcity of data available on patients who have initiated ART in recent years. The rate of scaleup in lowand middle-income countries over the past 4 years has been unprecedented: between the end of 2010 and the middle of 2014, the total number of individuals having ever started ART worldwide more than doubled from 6.6 million to 13.6 million people. Scale-up efforts have been aided by increases in the number of sites providing ART and the number of providers qualified to initiate new patients. However, we know very little about the outcomes of patients who have initiated ART in recent years, often at newer sites without research capacity. Although this new review includes published data until the end of 2013, only a small number of patients initiating ART in 2010 or later are included in the analysis. In addition, while the review was restricted to publications between 2008 and 2013, data were included from cohorts in the early 2000s and even 1990s. This challenge of ascertaining the outcomes of recently initiated patients is not due to a methodological oversight of the review but to the substantial delay between programmatic outcomes and publication. It is further compounded by the reality that studies reporting retention and mortality outcomes from routine observational ART cohorts are no longer regarded as priorities for publication. While this review used the most recently available data, including that from conference abstracts, it is still unlikely to give an accurate reflection of outcomes for patients initiating treatment today. In conclusion, we thank Fox and Rosen for continuing to highlight the important issue of retention. We urge journals to consider the publication of updated programme outcomes from recent ART cohorts. Given the scale-up of ART, changes in the models of care provision, thresholds for ART initiation, and first-line ART available to patients, we are in dire need of updated data from recent ART cohorts, as well as long-term outcomes of patients on ART in developing countries.
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Research Interests: Law, Human Rights, Political Science, Politics, Prejudice, and 15 moreInformed Consent, Developing Countries, Preventive medicine, Public Health, Medicine, Health and Human Rights, Humans, Female, Insurance, Confidentiality, Prisoners, Persons, Hiv seropositivity, Acquired immunodeficiency syndrome, and Delivery of Health Care
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Background Viral suppression in patients on antiretroviral treatment (ART) is critical to reducing HIV transmission and HIV-related mortality. Although many studies have evaluated factors associated with viral suppression, few have... more
Background Viral suppression in patients on antiretroviral treatment (ART) is critical to reducing HIV transmission and HIV-related mortality. Although many studies have evaluated factors associated with viral suppression, few have assessed the extent to which missing viral load data may bias results. Methods We included data on all patients starting ART from 2005 to 2019 in eight South African cohorts participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) collaboration. Multivariable logistic regression models were used to determine factors associated with having a viral load measurement within 2 months of a scheduled testing date and having a viral load <400 RNA copies/ml (‘viral suppression’). In a sensitivity analysis, missing viral loads were imputed based on patients’ clinical and demographic characteristics and outcomes. Results Viral load tests were scheduled in 603,549 and 77,423 intervals in adults and children, respectively, but test results...
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IntroductionMobility is associated with worse outcomes across the HIV treatment cascade, especially among men. However, little is known about the mechanisms that link mobility and poor HIV outcomes and what types of mobility most increase... more
IntroductionMobility is associated with worse outcomes across the HIV treatment cascade, especially among men. However, little is known about the mechanisms that link mobility and poor HIV outcomes and what types of mobility most increase the risk of treatment interruption among men in southern Africa.MethodsFrom August 2021 – January 2022, we conducted a mixed-methods study with men living with HIV (MLHIV) but not currently receiving antiretroviral therapy (ART) in Malawi. Data collection was embedded within two larger trials (ENGAGE and IDEaL trials). We analyzed baseline survey data of 223 men enrolled in the trials who reported being mobile (defined as spending ≥14 nights away from home in the past 12 months) using descriptive statistics and logistic regression. We then recruited 32 men for in-depth interviews regarding their travel experiences and ART utilization. We analyzed qualitative data using constant comparative methods.ResultsSurvey data showed that 34% of men with trea...
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comparison of death recording by health centres and civil
Older adolescents aged 15–19 years continue to have high rates of loss to follow up (LTFU), and high rates of virologic non‐suppression (VNS) compared to younger adolescents and adults. Adolescent females are at risk of pregnancy, which... more
Older adolescents aged 15–19 years continue to have high rates of loss to follow up (LTFU), and high rates of virologic non‐suppression (VNS) compared to younger adolescents and adults. Adolescent females are at risk of pregnancy, which puts those living with HIV at a dual vulnerability. Our study assessed the factors associated with VNS and LTFU in older adolescents (including pregnant females) who initiated antiretroviral therapy (ART) in South Africa.
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Background: Increased mortality among men on antiretroviral therapy (ART) has been documented but remains poorly understood. We examined the magnitude of and risk factors for gender differences in mortality on ART. Methods and Findings:... more
Background: Increased mortality among men on antiretroviral therapy (ART) has been documented but remains poorly understood. We examined the magnitude of and risk factors for gender differences in mortality on ART. Methods and Findings: Analyses included 46,201 ART-naı̈ve adults starting ART between January 2002 and December 2009 in eight ART programmes across South Africa (SA). Patients were followed from initiation of ART to outcome or analysis closure. The primary outcome was mortality; secondary outcomes were loss to follow-up (LTF), virologic suppression, and CD4+ cell count responses. Survival analyses were used to examine the hazard of death on ART by gender. Sensitivity analyses were limited to patients who were virologically suppressed and patients whose CD4+ cell count reached.200 cells/ml. We compared gender differences in mortality among HIV+ patients on ART with mortality in an age-standardised
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BackgroundMental disorders are common in people living with HIV (PLWH) but often remain untreated. We aimed to explore the gap in access to treatment (treatment gap) for mental disorders in adults followed-up in antiretroviral therapy... more
BackgroundMental disorders are common in people living with HIV (PLWH) but often remain untreated. We aimed to explore the gap in access to treatment (treatment gap) for mental disorders in adults followed-up in antiretroviral therapy (ART) programs in South Africa and disparities in access to mental health services.MethodsWe conducted a cohort study using ART program data and linked pharmacy and hospitalization data to estimate the 12-month prevalence of treatment for mental disorders (pharmacological or inpatient) and to examine factors associated with the rate of treatment for mental disorders among adults, aged 15-49 years, followed-up from January 1, 2012 to December 31, 2017 at one private care, two pubic primary care, and one public tertiary care ART programs in South Africa. We calculated the treatment gap for mental disorders as the discrepancy between the 12-month prevalence of mental disorders in PLWH (aged 15-49 years) in South Africa (estimated based on data from the Gl...
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Background: Tuberculosis (TB) has biological and socio-economic dimensions. The socio-economic impact of TB may plunge households into financial catastrophes. The End TB strategy seeks to mitigate socio-economic factors which may act as... more
Background: Tuberculosis (TB) has biological and socio-economic dimensions. The socio-economic impact of TB may plunge households into financial catastrophes. The End TB strategy seeks to mitigate socio-economic factors which may act as barriers to accessing TB services. Countries have been encouraged to provide baseline estimates of catastrophic costs by 2020. We sought to determine the prevalence, risk factors and major drivers of catastrophic costs among TB patients in Zimbabwe. Methods: We conducted a nationally representative, health facility-based survey with random cluster sampling among TB patients. We enrolled patients with drug susceptible (DS-TB) and drug resistant TB (DR-TB) consecutively. We administered a standardised questionnaire to capture the costs incurred as well as lost income due to TB illness. Catastrophic costs were measured at a threshold of 20%. We did a sensitivity analysis of indirect costs using the time lost by patients in each phase of treatment. We us...
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Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started... more
Low retention on combination antiretroviral therapy (cART) has emerged as a threat to the Joint United Nations Programme on human immunodeficiency virus (HIV)/AIDS (UNAIDS) 90-90-90 targets. We examined outcomes of patients who started cART but were subsequently lost to follow-up (LTFU) in African treatment programs. This was a systematic review and individual patient data meta-analysis of studies that traced patients who were LTFU. Outcomes were analyzed using cumulative incidence functions and proportional hazards models for the competing risks of (i) death, (ii) alive but stopped cART, (iii) silent transfer to other clinics, and (iv) retention on cART. Nine studies contributed data on 7377 patients who started cART and were subsequently LTFU in sub-Saharan Africa. The median CD4 count at the start of cART was 129 cells/μL. At 4 years after the last clinic visit, 21.8% (95% confidence interval [CI], 20.8%-22.7%) were known to have died, 22.6% (95% CI, 21.6%-23.6%) were alive but h...
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There is uncertainty regarding the completeness of death recording by civil registration and by health centres in South Africa. This paper aims to compare death recording by the two systems, in cohorts of South African patients receiving... more
There is uncertainty regarding the completeness of death recording by civil registration and by health centres in South Africa. This paper aims to compare death recording by the two systems, in cohorts of South African patients receiving antiretroviral treatment (ART). Completeness of death recording was estimated using a capture-recapture approach. Six ART programmes linked their patient record systems to the vital registration system using civil identity document (ID) numbers and provided data comparing the outcomes recorded in patient files and in the vital registration. Patients were excluded if they had missing/invalid IDs or had transferred to other ART programmes. After exclusions, 91,548 patient records were included. Of deaths recorded in patients files after 2003, 94.0% (95% CI: 93.3-94.6%) were recorded by civil registration, with completeness being significantly higher in urban areas, older adults and females. Of deaths recorded by civil registration after 2003, only 35....
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Summary Background As access to antiretroviral therapy (ART) expands, increasing numbers of older patients will start treatment and need specialised long-term care. However, the eff ect of age in ART programmes in resource-constrained... more
Summary
Background As access to antiretroviral therapy (ART) expands, increasing numbers of older patients will start
treatment and need specialised long-term care. However, the eff ect of age in ART programmes in resource-constrained
settings is poorly understood. The HIV epidemic is ageing rapidly and South Africa has one of the highest HIV
population prevalences worldwide. We explored the eff ect of age on mortality of patients on ART in South Africa and
whether this eff ect is mediated by baseline immunological status.
Methods In this retrospective cohort analysis, we studied HIV-positive patients aged 16–80 years who started ART for
the fi rst time in six large South African cohorts of the International Epidemiologic Databases to Evaluate AIDSSouthern
Africa collaboration, in KwaZulu-Natal, Gauteng, and Western Cape (two primary care clinics, three
hospitals, and a large rural cohort). The primary outcome was mortality. We ascertained patients’ vital status through
linkage to the National Population Register. We used inverse probability weighting to correct mortality for loss to
follow-up. We estimated mortality using Cox’s proportional hazards and competing risks regression. We tested the
interaction between baseline CD4 cell count and age.
Findings Between Jan 1, 2004, and Dec 31, 2013, 84 078 eligible adults started ART. Of these, we followed up
83 566 patients for 174 640 patient-years. 8% (1817 of 23 258) of patients aged 16–29 years died compared with 19%
(93 of 492) of patients aged 65 years or older. The age adjusted mortality hazard ratio was 2·52 (95% CI 2·01–3·17) for
people aged 65 years or older compared with those 16–29 years of age. In patients starting ART with a CD4 count of
less than 50 cells per μL, the adjusted mortality hazard ratio was 2·52 (2·04–3·11) for people aged 50 years or older
compared with those 16–39 years old. Mortality was highest in patients with CD4 counts of less than 50 cells per μL,
and 15% (1103 of 7295) of all patients aged 50 years or older starting ART were in this group. The proportion of
patients aged 50 years or older enrolling in ART increased with successive years, from 6% (290 of 4999) in 2004 to
10% (961 of 9657) in 2012–13, comprising 9% of total enrolment (7295 of 83 566). At the end of the study, 6304 (14%)
of 44 909 patients still alive and in care were aged 50 years or older.
Background As access to antiretroviral therapy (ART) expands, increasing numbers of older patients will start
treatment and need specialised long-term care. However, the eff ect of age in ART programmes in resource-constrained
settings is poorly understood. The HIV epidemic is ageing rapidly and South Africa has one of the highest HIV
population prevalences worldwide. We explored the eff ect of age on mortality of patients on ART in South Africa and
whether this eff ect is mediated by baseline immunological status.
Methods In this retrospective cohort analysis, we studied HIV-positive patients aged 16–80 years who started ART for
the fi rst time in six large South African cohorts of the International Epidemiologic Databases to Evaluate AIDSSouthern
Africa collaboration, in KwaZulu-Natal, Gauteng, and Western Cape (two primary care clinics, three
hospitals, and a large rural cohort). The primary outcome was mortality. We ascertained patients’ vital status through
linkage to the National Population Register. We used inverse probability weighting to correct mortality for loss to
follow-up. We estimated mortality using Cox’s proportional hazards and competing risks regression. We tested the
interaction between baseline CD4 cell count and age.
Findings Between Jan 1, 2004, and Dec 31, 2013, 84 078 eligible adults started ART. Of these, we followed up
83 566 patients for 174 640 patient-years. 8% (1817 of 23 258) of patients aged 16–29 years died compared with 19%
(93 of 492) of patients aged 65 years or older. The age adjusted mortality hazard ratio was 2·52 (95% CI 2·01–3·17) for
people aged 65 years or older compared with those 16–29 years of age. In patients starting ART with a CD4 count of
less than 50 cells per μL, the adjusted mortality hazard ratio was 2·52 (2·04–3·11) for people aged 50 years or older
compared with those 16–39 years old. Mortality was highest in patients with CD4 counts of less than 50 cells per μL,
and 15% (1103 of 7295) of all patients aged 50 years or older starting ART were in this group. The proportion of
patients aged 50 years or older enrolling in ART increased with successive years, from 6% (290 of 4999) in 2004 to
10% (961 of 9657) in 2012–13, comprising 9% of total enrolment (7295 of 83 566). At the end of the study, 6304 (14%)
of 44 909 patients still alive and in care were aged 50 years or older.
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Summary Background As access to antiretroviral therapy (ART) expands, increasing numbers of older patients will start treatment and need specialised long-term care. However, the eff ect of age in ART programmes in resource-constrained... more
Summary
Background As access to antiretroviral therapy (ART) expands, increasing numbers of older patients will start
treatment and need specialised long-term care. However, the eff ect of age in ART programmes in resource-constrained
settings is poorly understood. The HIV epidemic is ageing rapidly and South Africa has one of the highest HIV
population prevalences worldwide. We explored the eff ect of age on mortality of patients on ART in South Africa and
whether this eff ect is mediated by baseline immunological status.
Methods In this retrospective cohort analysis, we studied HIV-positive patients aged 16–80 years who started ART for
the fi rst time in six large South African cohorts of the International Epidemiologic Databases to Evaluate AIDSSouthern
Africa collaboration, in KwaZulu-Natal, Gauteng, and Western Cape (two primary care clinics, three
hospitals, and a large rural cohort). The primary outcome was mortality. We ascertained patients’ vital status through
linkage to the National Population Register. We used inverse probability weighting to correct mortality for loss to
follow-up. We estimated mortality using Cox’s proportional hazards and competing risks regression. We tested the
interaction between baseline CD4 cell count and age.
Findings Between Jan 1, 2004, and Dec 31, 2013, 84 078 eligible adults started ART. Of these, we followed up
83 566 patients for 174 640 patient-years. 8% (1817 of 23 258) of patients aged 16–29 years died compared with 19%
(93 of 492) of patients aged 65 years or older. The age adjusted mortality hazard ratio was 2·52 (95% CI 2·01–3·17) for
people aged 65 years or older compared with those 16–29 years of age. In patients starting ART with a CD4 count of
less than 50 cells per μL, the adjusted mortality hazard ratio was 2·52 (2·04–3·11) for people aged 50 years or older
compared with those 16–39 years old. Mortality was highest in patients with CD4 counts of less than 50 cells per μL,
and 15% (1103 of 7295) of all patients aged 50 years or older starting ART were in this group. The proportion of
patients aged 50 years or older enrolling in ART increased with successive years, from 6% (290 of 4999) in 2004 to
10% (961 of 9657) in 2012–13, comprising 9% of total enrolment (7295 of 83 566). At the end of the study, 6304 (14%)
of 44 909 patients still alive and in care were aged 50 years or older.
Background As access to antiretroviral therapy (ART) expands, increasing numbers of older patients will start
treatment and need specialised long-term care. However, the eff ect of age in ART programmes in resource-constrained
settings is poorly understood. The HIV epidemic is ageing rapidly and South Africa has one of the highest HIV
population prevalences worldwide. We explored the eff ect of age on mortality of patients on ART in South Africa and
whether this eff ect is mediated by baseline immunological status.
Methods In this retrospective cohort analysis, we studied HIV-positive patients aged 16–80 years who started ART for
the fi rst time in six large South African cohorts of the International Epidemiologic Databases to Evaluate AIDSSouthern
Africa collaboration, in KwaZulu-Natal, Gauteng, and Western Cape (two primary care clinics, three
hospitals, and a large rural cohort). The primary outcome was mortality. We ascertained patients’ vital status through
linkage to the National Population Register. We used inverse probability weighting to correct mortality for loss to
follow-up. We estimated mortality using Cox’s proportional hazards and competing risks regression. We tested the
interaction between baseline CD4 cell count and age.
Findings Between Jan 1, 2004, and Dec 31, 2013, 84 078 eligible adults started ART. Of these, we followed up
83 566 patients for 174 640 patient-years. 8% (1817 of 23 258) of patients aged 16–29 years died compared with 19%
(93 of 492) of patients aged 65 years or older. The age adjusted mortality hazard ratio was 2·52 (95% CI 2·01–3·17) for
people aged 65 years or older compared with those 16–29 years of age. In patients starting ART with a CD4 count of
less than 50 cells per μL, the adjusted mortality hazard ratio was 2·52 (2·04–3·11) for people aged 50 years or older
compared with those 16–39 years old. Mortality was highest in patients with CD4 counts of less than 50 cells per μL,
and 15% (1103 of 7295) of all patients aged 50 years or older starting ART were in this group. The proportion of
patients aged 50 years or older enrolling in ART increased with successive years, from 6% (290 of 4999) in 2004 to
10% (961 of 9657) in 2012–13, comprising 9% of total enrolment (7295 of 83 566). At the end of the study, 6304 (14%)
of 44 909 patients still alive and in care were aged 50 years or older.