Congrats to MSF for analysing data.

“There is an urgent need to determine sustainable and optimal models of care for stable patients on lifelong ART,” the MSF team concludes, “especially in large programs in high-prevalence resource-limited settings.”

This is true in Myanmar as programmes rapidly increase their intake, queues decrease in size, people with higher CD4 cell counts enter treatment, and more people outside Yangon and Mandalay begin ART.

Jamie

++++++++++++++++++

Bigger MSF ART Programs Mean Lower Mortality, More Dropouts
Author: Mark Mascolini
IAS
10 November 2014

Larger antiretroviral therapy (ART) program size was associated with lower mortality but with higher loss to follow-up in a 25-program Médecins Sans Frontières (MSF) analysis in Africa and Asia.
Antiretroviral programs expanded rapidly in many parts of the world starting around 2000. Because little is known about how rapid program expansion affects mortality and loss to follow-up (dropping out of care), MSF researchers conducted this analysis of people starting ART in 25 African and Asian programs from 2001 through 2011. They used Kaplan-Meier analysis to describe time to death and loss to follow-up.
The study involved 132,334 people in 8 low- and middle-income countries, 61% of them female, with a median age of 35 years. Overall mortality 36 months after starting ART fell from 22% in 2003 to 9% in 2008, but loss to follow-up rose from 11% to 21%.
Compared with 2001-2003, hazard ratios (HR) for early (0- to 12-month) loss to follow-up and late (12- to 72-month) loss to follow-up rose over time, from 1.09 (95% confidence interval [CI] 0.83 to 1.43) and 1.04 (95% CI 0.84 to 1.28) in 2004 to 3.29 (95% CI 2.42 to 4.46) and 6.86 (95% CI 4.94 to 9.53) in 2011.
ART programs that expanded faster had greater early and late loss to follow-up. For programs with 125 or more patients versus under 25 patients per month, the adjusted hazard ratio for early loss to follow-up was 2.31 (95% CI 1.78 to 3.01), while the adjusted hazard ratio for late loss to follow-up was 2.29 (95% CI 1.76 to 2.99).
Risk of early loss to follow-up was 77% higher in programs with 20,000 or more patients versus under 500 patients (aHR 1.77, 95% CI 1.04 to 3.04). In contrast, larger program size was linked to a halving of early mortality (aHR 0.49, 95% CI 0.31 to 0.77).
Bigger MSF ART Programs Mean Lower Mortality, More Dropouts
Author: Mark Mascolini
10 November 2014
Larger antiretroviral therapy (ART) program size was associated with lower mortality but with higher loss to follow-up in a 25-program Médecins Sans Frontières (MSF) analysis in Africa and Asia.
Antiretroviral programs expanded rapidly in many parts of the world starting around 2000. Because little is known about how rapid program expansion affects mortality and loss to follow-up (dropping out of care), MSF researchers conducted this analysis of people starting ART in 25 African and Asian programs from 2001 through 2011. They used Kaplan-Meier analysis to describe time to death and loss to follow-up.
The study involved 132,334 people in 8 low- and middle-income countries, 61% of them female, with a median age of 35 years. Overall mortality 36 months after starting ART fell from 22% in 2003 to 9% in 2008, but loss to follow-up rose from 11% to 21%.
Compared with 2001-2003, hazard ratios (HR) for early (0- to 12-month) loss to follow-up and late (12- to 72-month) loss to follow-up rose over time, from 1.09 (95% confidence interval [CI] 0.83 to 1.43) and 1.04 (95% CI 0.84 to 1.28) in 2004 to 3.29 (95% CI 2.42 to 4.46) and 6.86 (95% CI 4.94 to 9.53) in 2011.
ART programs that expanded faster had greater early and late loss to follow-up. For programs with 125 or more patients versus under 25 patients per month, the adjusted hazard ratio for early loss to follow-up was 2.31 (95% CI 1.78 to 3.01), while the adjusted hazard ratio for late loss to follow-up was 2.29 (95% CI 1.76 to 2.99).
Risk of early loss to follow-up was 77% higher in programs with 20,000 or more patients versus under 500 patients (aHR 1.77, 95% CI 1.04 to 3.04). In contrast, larger program size was linked to a halving of early mortality (aHR 0.49, 95% CI 0.31 to 0.77).
“There is an urgent need to determine sustainable and optimal models of care for stable patients on lifelong ART,” the MSF team concludes, “especially in large programs in high-prevalence resource-limited settings.”
They suggest that “decreasing visit frequency by expanding intervals between prescription refills, decentralizing ART delivery into community-based patient-led groups, and introducing flexible systems to support mobile populations are all interventions that could be considered and assessed on a large scale.”
Source: Anna Grimsrud, Suna Balkan, Esther C. Casas, Johnny Lujan, Gilles Van Cutsem, Elisabeth Poulet, Landon Myer, Mar Pujades-Rodriguez. Outcomes of antiretroviral therapy over a 10-year period of expansion: a multicohort analysis of African and Asian HIV programs. JAIDS. 2014; 67: e55-e66.
They suggest that “decreasing visit frequency by expanding intervals between prescription refills, decentralizing ART delivery into community-based patient-led groups, and introducing flexible systems to support mobile populations are all interventions that could be considered and assessed on a large scale.”
Source: Anna Grimsrud, Suna Balkan, Esther C. Casas, Johnny Lujan, Gilles Van Cutsem, Elisabeth Poulet, Landon Myer, Mar Pujades-Rodriguez. Outcomes of antiretroviral therapy over a 10-year period of expansion: a multicohort analysis of African and Asian HIV programs. JAIDS. 2014; 67: e55-e66.

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