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Objective To analyse survival and retention rates of the Tanzanian care and treatment programme.
Methods Routine patient-level data were available from 101 of 909 clinics. Kaplan–Meier probabilities of mortality and attrition after ART initiation were calculated. Mortality risks were corrected for biases from loss to follow-up using Egger’s nomogram. Smoothed hazard rates showed mortality and attrition peaks. Cox regression identified factors associated with death and attrition. Median CD4 counts were calculated at 6 month intervals.
Results In 88,875 adults, 18% were lost to follow up 12 months after treatment initiation, and 36% after 36 months. Cumulative mortality reached 10% by 12 months (15% after correcting for loss to follow-up) and 14% by 36 months. Mortality and attrition rates both peaked within the first six months, and were higher among males, those under 45 kg and those with CD4 counts below 50 cells/μl at ART initiation. In the first year on ART, median CD4 count increased by 126 cells/μl, with similar changes in both sexes.
Conclusion Earlier diagnoses through expanded HIV testing may reduce high mortality and attrition rates if combined with better patient tracing systems. Further research is needed to explore reasons for attrition.
Objectif: Analyser les taux de survie et de rétention dans le programme tanzanien de soins et traitement.
Méthodes: Les données de routine des patients étaient disponibles dans 101 des 909 cliniques. Les probabilités de Kaplan-Meier pour la mortalité et de désistement après l’initiation de l’ART ont été calculées. Les risques de mortalité ont été corrigés pour les biais liés à la perte au suivi à l’aide du nomogramme Egger. Les taux de risque ajustés montrent des pics de mortalité et de désistement. La régression de Cox a identifié les facteurs associés à la mort et au désistement. Les taux médian de CD4 ont été calculés par intervalles de 6 mois.
Résultats: Chez 88.875 adultes, 18% ont été perdus au suivi 12 mois après l’initiation du traitement et 36%, 36 mois après. La mortalité cumulée a atteint 10% en 12 mois (15% après correction pour les pertes au suivi) et 14% en 36 mois. Les taux de mortalité et le désistement ont atteint un pic endéans les six premiers mois et étaient plus élevés chez les hommes, ceux de moins de 45 kg et ceux dont la numération des CD4 était inférieure à 50 cellules/μl lors de l’initiation de l’ART. Dans la première année sous ART, le nombre médian de CD4 a augmenté de 126 cellules/μl, avec des changements semblables pour les deux sexes.
Conclusion: Un diagnostic plus précoce grâce à l’extension des tests VIH pourrait réduire les taux élevés de mortalité et de désistement s’il est combiné avec un meilleur système de traçage des patients. Des recherches supplémentaires sont nécessaires pour explorer les raisons du désistement.
Objetivo: Analizar las tasas de supervivencia y retención dentro del programa Nacional de Cuidados y Tratamiento del VIH de Tanzania.
Métodos: Se contó con datos de rutina de pacientes de 101 de 909 clínicas. Mediante la prueba de Kaplan-Meier se calcularon las probabilidades de mortalidad y desgaste después de la iniciación del TAR. Se corrigió el sesgo de la pérdida durante el seguimiento en el riesgo de mortalidad utilizando el nomograma de Egger. Las tasas de riesgo mostraban los picos de mortalidad y desgaste. La regresión de Cox identificó factores asociados con la muerte y desgaste. Los conteos medios de CD4 se calcularon en intervalos de 6 meses.
Resultado: De 88,875 adultos, un 18% se perdió durante el seguimiento tras 12 meses después de iniciado el tratamiento, y un 36% tras 36 meses. La mortalidad acumulativa alcanzó un 10% a los 12 meses (15% tras corregir la pérdida durante el seguimiento) y 14% a los 36 meses. Las tasas de mortalidad y desgaste aumentaron ambas dentro de los seis primeros meses, y eran mayores entre hombres, aquellos con menos de 45kg y aquellos con conteos de CD4 por debajo de 50 células/μl al momento de iniciar TAR. Durante el primer año recibiendo TAR, el conteo medio de CD4 aumentó en 126 células/μl, con cambios similares en ambos sexos.
Conclusión: Los diagnósticos tempranos mediante la prueba ampliada de VIH puede reducir unas altas tasas de mortalidad y desgaste si se combina con mejores sistemas de seguimiento de los pacientes. Se requieren más estudios para explorar razones para el desgaste.
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HIV care and treatment programmes have scaled up rapidly over the past 5 years in sub-Saharan Africa, with large increases in numbers initiating treatment, and substantial mortality declines in the HIV infected population (UNAIDS 2010; WHO 2010). Estimated ART coverage in the region increased from 28% to 37% from December 2008 to December 2009 (WHO 2010).
However, increases in ART uptake have been accompanied by rising attrition in national programmes (Brinkhof et al. 2008; Cornell et al. 2010; WHO 2010). Meta-analyses of sub-Saharan African ART programmes have yielded cumulative retention figures of 75–80% after 12 months on treatment and 67–77% at 24 months (Fox & Rosen 2010; Tassie et al. 2010). High attrition leads to underestimates of mortality on ART as patients lost to follow-up experience higher mortality than those remaining in programmes (Brinkhof et al. 2009b). Rigorous monitoring systems are needed to ensure accurate estimates of programme performance indicators such as attrition, mortality and treatment outcomes.
Country-level analyses of routinely collected patient data in national programmes are important for evaluating programme performance over time. Despite numerous studies of ART patient outcomes in sub-Saharan Africa, few countries have presented national-level data from multiple sites incorporated into their ART programmes. Cohort analyses of patients in national programmes are often restricted to sub-regions (Boulle et al. 2008), or small sample sizes (Bussmann et al. 2008; Lowrance et al. 2009; Cornell et al. 2010). This paper is the first to report detailed national estimates of retention, mortality and treatment outcomes and their determinants in the Tanzanian ART programme, based on routinely reported individual-level data from 88 875 patients in 101 clinics over 5 years, with the aim of informing government efforts to improve programme performance and patient outcomes.
By 2007, it was estimated that 1.4 million people were living with HIV in Tanzania, corresponding to an adult prevalence of 5.7% (TACAIDS et al. 2008). The National AIDS Control Programme (NACP) is responsible for prevention, care and treatment services, and programme monitoring and evaluation. The Government started providing free ART for eligible patients (defined by a CD4 count <200 cells/μl or WHO stage 4) at the end of 2004, and rapidly decentralised treatment to regional and district hospitals in 2005, and health centres from 2007. By the end of 2009, Tanzania had approved 909 facilities to provide care and treatment services, enabling more than 300 000 patients to access ART.
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Routinely collected data from Tanzania’s national ART programme were used in a large-scale cohort analysis of mortality, attrition and CD4 response over time on ART, shedding light on the performance of the Tanzanian programme and the effect of the rapid scale-up on patient outcomes. Restricting the analysis to the 101 clinics with patient-level electronic data may have biased the estimates of mortality and attrition for the Tanzanian programme, since these clinics are generally larger, better equipped facilities, situated in more urban areas: of the 909 ART clinics 28% are hospitals, 51% health centres and 21% dispensaries, whereas the respective proportions contributing electronic data are 71%, 21% and 8% (NACP 2010). Recently established small, decentralised clinics are less likely to have computer equipment.
Patients from computerised clinics may differ systematically from those in other clinics, though it is difficult to determine in which direction this might bias estimates: while small decentralised clinics might be less well equipped than urban clinics, they can provide a more intimate follow up, and large hospitals may provide better services but attract patients with more advanced infection who have worse outcomes (TRAC 2008; Mutevedzi et al. 2010). In our study, no differences were identified in outcomes by type of facility, suggesting that restricting the analysis to the 101 clinics did not bias the estimates. As more clinics start collecting electronic data, it will become possible to investigate differences in patient outcomes between clinics included in this analysis and newly computerised clinics.
The 101 clinics are drawn from only 10 of the 23 regions in Tanzania, and may not be representative of the programme as a whole. However, the 10 regions span rural and urban areas across the country, and represent a range of HIV prevalence levels (from 1.8% to 15.7%) similar to the range for all 23 regions (1.5–15.7%) (TACAIDS et al. 2008). CTC programme coverage in the 10 regions ranged from 13% to 29%, compared to 21% nationally (11–42% over all 23 regions) (NACP 2010). These figures suggest the 10 regions were fairly representative of Tanzania in terms of HIV prevalence and coverage of care and treatment services.
Using routine data has the advantage of providing a realistic assessment of the performance of the ART programme in ordinary government clinics, in contrast to using data from research or trial clinics, where the majority of data on patient outcomes has been reported. Although these best-practice clinics often perform well, these successes cannot easily be translated to lower-resource clinics during programme scale-up.
Mortality risks in the Tanzanian programme are broadly comparable to those found in other African programmes (Egger et al. 2011). Mortality decline in the maturing programme is likely due to a combination of better programme delivery, improved treatment options, and more timely ART initiation: patients started ART at increasingly high CD4 counts between 2005 and 2009. Mortality rates peak in the first few months after ART initiation, then decline steeply, as commonly found in other programmes in low-income countries (Braitstein et al. 2006; Van Cutsem et al. 2011).
Probabilities of attrition in the Tanzanian programme are also similar to those found in other sub-Saharan African programmes (Fox and Rosen 2010; Tassie et al. 2010). Unlike mortality, attrition rates were more sustained over time from ART initiation, suggesting that loss to follow-up in later years is caused by factors other than death, which hinder clinic attendance or adherence to treatment. The finding that loss to follow-up increases over time as the programme is scaled up is corroborated by results from a cross-national study (Brinkhof et al. 2008), and may be due to increased difficulties of tracking a rapidly growing number of patients in expanding programmes. This calls for improved monitoring systems informed by research on the causes of attrition, in order to keep track of patient outcomes and evaluate programme performance. Various interventions have been shown to improve retention, including reducing costs to patients, using community outreach teams, building stronger links between health services and the community, and avoiding drug stock-outs (Forster et al. 2008; Harries et al. 2010). Patient tracing schemes, while effective in reducing loss to follow-up, are more costly (Rosen & Ketlhapile 2010; Tweya et al. 2010).
The improvements in median CD4 counts over time, and differences by baseline characteristics, are similar to those found in a multi-country cohort analysis of CD4 response to ART (Nash et al. 2008). Unsurprisingly, patients who subsequently died showed smaller improvements in CD4 counts compared to those who survived. In contrast, CD4 trajectories of patients lost to follow-up resembled more closely those of patients in follow-up than those of patients who died, indicating that death accounts for a relatively smaller proportion of loss to follow-up in patients with improving CD4 counts.
The higher mortality of men compared to women may be partly explained by men’s lower baseline CD4 counts. This highlights the need for interventions to ensure timely ART initiation in men. Similar associations between mortality and age, CD4 count, WHO stage and weight have been found in other sub-Saharan African programmes (Palombi et al. 2009; May et al. 2010). In particular, national and cross-national analyses in low-income countries have shown that low CD4 count at ART start is a major risk factor for mortality, further emphasising the importance of timely ART initiation (Brinkhof et al. 2009a; Johansson et al. 2010; May et al. 2010).
In light of this, the increase in CD4 counts at ART initiation over time is promising. However, the median baseline CD4 count in Tanzania, at 155 cells/μl in 2009, is still well below the WHO recommended threshold for ART initiation, which was recently increased from 200 to 350 cells/μl (WHO 2010). Patients in low-income countries continue to start ART at much lower CD4 counts than those in high-income countries, and differences persist even after 6 months on treatment, leading to higher mortality in patients from low-income countries (Braitstein et al. 2006). Ensuring timely ART initiation at higher CD4 counts, through expanded HIV testing and clinic decentralisation, could help reduce the high first-year mortality of patients, as well as improving retention (Chan et al. 2010). These measures, coupled with improved systems for monitoring patients lost to follow-up, would enable a more accurate assessment of Tanzania’s programme impact.
This analysis of routine data from the Tanzanian Programme highlighted several improvements in performance over time, such as mortality reduction and more timely treatment initiation at increasing CD4 counts. The programme should continue investing efforts in raising the mean CD4 count at initiation to the WHO recommended threshold through expanded HIV testing, paying particular attention to men, whose lower baseline CD4 counts contribute to their persistently higher mortality. The other major remaining challenge is improving retention. Given that the majority of loss to follow-up does not appear to be death-related, more research is needed to understand the causes of attrition, in order to develop interventions to keep patients on treatment and reintegrate those lost to follow-up (including those with high CD4 counts) back into the programme before their health deteriorates. As one of the causes of attrition is transferring to non-computerised clinics, improving reporting of transfers and record linking between clinics will be key to improving performance. These are priority issues to address in order to ensure that recent achievements in ART access and outcomes can be built on to pave the way towards universal treatment access in Tanzania.