Variation in attrition at subnational level: review of the Botswana National HIV/AIDS Treatment (Masa) programme data (2002-2013).

OBJECTIVE: To evaluate the variation in all-cause attrition [mortality and loss to follow-up (LTFU)] among HIV-infected individuals in Botswana by health district during the rapid and massive scale-up of the National Treatment Program. METHODS: Analysis of routinely collected longitudinal data from 226 030 patients who received ART through the Botswana National HIV/AIDS Treatment Program across all 24 health districts from 2002 to 2013. A time-to-event analysis was used to measure crude mortality and loss to follow-up rates (LTFU). A marginal structural model was used to evaluate mortality and LTFU rates by district over time, adjusted for individual-level risk factors (e.g. age, gender, baseline CD4, year of treatment initiation and antiretroviral regimen). RESULTS: Mortality rates in the districts ranged from the lowest 1.0 (95% CI 0.9-1.1) in Selibe-Phikwe, to the highest 5.0 (95% CI 4.0-6.1), in Mabutsane. There was a wide range of overall LTFU across districts, including rates as low as 4.6 (95% CI 4.4-4.9) losses per 100 person-years in Ngamiland, and 5.9 (95% CI 5.6-6.2) losses per 100 person-years in South East district, to rates as high as 25.4 (95% CI 23.08-27.89) losses per 100 person-years in Mabutsane and 46.3 (95% CI 43.48-49.23) losses per 100 person-years in Okavango. Even when known risk factors for mortality and LTFU were adjusted for, district was a significant predictor of both mortality and LTFU rates. CONCLUSION: We found statistically significant variation in attrition (mortality and LTFU) and data quality among districts. These findings suggest that district-level contextual factors affect retention in treatment. Further research needs to investigate factors that can potentially cause this variation.

Lower Levels of Antiretroviral Therapy Enrollment Among Men with HIV Compared with Women - 12 Countries, 2002-2013.

Equitable access to antiretroviral therapy (ART) for men and women with human immunodeficiency virus (HIV) infection is a principle endorsed by most countries and funding bodies, including the U.S. President's Emergency Plan for AIDS (acquired immunodeficiency syndrome) Relief (PEPFAR) (1). To evaluate gender equity in ART access among adults (defined for this report as persons aged ≥15 years), 765,087 adult ART patient medical records from 12 countries in five geographic regions* were analyzed to estimate the ratio of women to men among new ART enrollees for each calendar year during 2002-2013. This annual ratio was compared with estimates from the Joint United Nations Programme on HIV/AIDS (UNAIDS)(†) of the ratio of HIV-infected adult women to men in the general population. In all 10 African countries and Haiti, the most recent estimates of the ratio of adult women to men among new ART enrollees significantly exceeded the UNAIDS estimates for the female-to-male ratio among HIV-infected adults by 23%-83%. In six African countries and Haiti, the ratio of women to men among new adult ART enrollees increased more sharply over time than the estimated UNAIDS female-to-male ratio among adults with HIV in the general population. Increased ART coverage among men is needed to decrease their morbidity and mortality and to reduce HIV incidence among their sexual partners. Reaching more men with HIV testing and linkage-to-care services and adoption of test-and-treat ART eligibility guidelines (i.e., regular testing of adults, and offering treatment to all infected persons with ART, regardless of CD4 cell test results) could reduce gender inequity in ART coverage.

Trends and determinants of survival for over 200 000 patients on antiretroviral treatment in the Botswana National Program: 2002-2013.

OBJECTIVES: To determine the incidence and risk factors of mortality for all HIV-infected patients receiving antiretroviral treatment at public and private healthcare facilities in the Botswana National HIV/AIDS Treatment Programme. DESIGN: We studied routinely collected data from 226 030 patients enrolled in the Botswana National HIV/AIDS Treatment Programme from 2002 to 2013. METHODS: A person-years (P-Y) approach was used to analyse all-cause mortality and follow-up rates for all HIV-infected individuals with documented antiretroviral therapy initiation dates. Marginal structural modelling was utilized to determine the effect of treatment on survival for those with documented drug regimens. Sensitivity analyses were performed to assess the robustness of our results. RESULTS: Median follow-up time was 37 months (interquartile range 11-75). Mortality was highest during the first 3 months after treatment initiation at 11.79 (95% confidence interval 11.49-12.11) deaths per 100 P-Y, but dropped to 1.01 (95% confidence interval 0.98-1.04) deaths per 100 P-Y after the first year of treatment. Twelve-month mortality declined from 7 to 2% of initiates during 2002-2012. Tenofovir was associated with lower mortality than stavudine and zidovudine. CONCLUSION: The observed mortality rates have been declining over time; however, mortality in the first year, particularly first 3 months of antiretroviral treatment, remains a distinct problem. This analysis showed lower mortality with regimens containing tenofovir compared with zidovudine and stavudine. CD4 cell count less than 100 cells/µl, older age and being male were associated with higher odds of mortality.

Impact of Health System Inputs on Health Outcome: A Multilevel Longitudinal Analysis of Botswana National Antiretroviral Program (2002-2013).

OBJECTIVE: To measure the association between the number of doctors, nurses and hospital beds per 10,000 people and individual HIV-infected patient outcomes in Botswana. DESIGN: Analysis of routinely collected longitudinal data from 97,627 patients who received ART through the Botswana National HIV/AIDS Treatment Program across all 24 health districts from 2002 to 2013. Doctors, nurses, and hospital bed density data at district-level were collected from various sources. METHODS: A multilevel, longitudinal analysis method was used to analyze the data at both patient- and district-level simultaneously to measure the impact of the health system input at district-level on probability of death or loss-to-follow-up (LTFU) at the individual level. A marginal structural model was used to account for LTFU over time. RESULTS: Increasing doctor density from one doctor to two doctors per 10,000 population decreased the predicted probability of death for each patient by 27%. Nurse density changes from 20 nurses to 25 nurses decreased the predicted probability of death by 28%. Nine percent decrease was noted in predicted mortality of an individual in the Masa program for every five hospital bed density increase. CONCLUSION: Considerable variation was observed in doctors, nurses, and hospital bed density across health districts. Predictive margins of mortality and LTFU were inversely correlated with doctor, nurse and hospital bed density. The doctor density had much greater impact than nurse or bed density on mortality or LTFU of individual patients. While long-term investment in training more healthcare professionals should be made, redistribution of available doctors and nurses can be a feasible solution in the short term.