Treatment Outcomes and Cost-Effectiveness of Shifting Management of Stable ART Patients to Nurses in South Africa: An Observational Cohort

Lawrence Long and colleagues report that “down-referring” stable HIV patients from a doctor-managed, hospital-based ART clinic to a nurse-managed primary health facility provides good health outcomes and cost-effective treatment for patients

Incidence of Pregnancy after Initiation of Antiretroviral Therapy in South Africa: A Retrospective Clinical Cohort Analysis

Background. Little is known about rates of incident pregnancy among HIV-positive women initiating highly active antiretroviral therapy (HAART). Methods. We conducted a retrospective clinical cohort study among therapy-naïve women ages 18–45 initiating HAART between 1 April 2004 and 30 September 2009 at an adult HAART clinic in Johannesburg, South Africa. We used Poisson regression to characterize rates and rate ratios of pregnancy. Results. We evaluated 5,996 women who experienced 727 pregnancies during 14,095 person-years at risk. The overall rate of pregnancy was 5.2 per 100 person-years (95% confidence limits [CL] 4.8, 5.5). By six years, cumulative incidence of first pregnancy was 22.9% (95% CL 20.6%, 25.4%); among women ages 18–25 at HAART initiation, cumulative incidence was 52.2% (95% CL 35.0%, 71.8%). The strongest predictor of incidence of pregnancy was age, with women 18–25 having 13.2 times the rate of pregnancy of women ages 40–45 in adjusted analysis. CD4 counts below 100 and worse adherence to HAART were associated with lower rates of incident pregnancy. Conclusions. Women experience high rates of incident pregnancy after HAART initiation. Understanding which women are most likely to experience pregnancy will help planning and future efforts to understand the implications of pregnancy for response to HAART

Characteristics of ART patients at the time of eligibility for down-referral to nurse-managed care.

a<p>These characteristics were matched between the two samples.</p>b<p>Note that 15.4% of participants in the treatment-initiation sample and 11.5% in the down-referral sample did not have baseline CD4 counts reported.</p><p>IQR, inter-quartile range.</p

Average cost per patient, by HIV treatment outcome and cost component.

<p>Costs are given in 2009 US dollars, converted at a rate of R8.40 to US$1.00.</p>a<p><i>p</i><0.001 for difference between treatment-initiation and down-referral patients.</p>b<p>Only patients who were still in care and responding at 12 mo were included.</p

Average resource utilization and selected unit costs for the study sample (<i>n</i> = 2,160) over 12 mo from the date of down-referral eligibility.

a<p>Costs were converted to US dollars at a rate of R8.40 to US$1.00.</p

Criteria for assigning HIV treatment outcomes.

<p>Criteria for assigning HIV treatment outcomes.</p

Decision process for assigning HIV treatment outcomes.

<p>Patients were placed in a mutually exclusive patient outcome category 12 mo after study enrolment – no longer in care, in care and responding or in care and not responding. Patient outcomes were defined based on the patient's vital status, presence in the clinic, viral load or CD4 count at 12 mo after study enrolment. For those patients alive and in treatment, viral load was the preferred outcome indicator, but in the absence of viral load CD4 count was used and if neither were available then it was assumed the patient was in care and responding based on their presence in the clinic. The diagnostic result closest to 12 mo, but within 3 mo (9–15 mo) was used.</p