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Monitoring of Antiretroviral Therapy and Mortality in HIV Programmes in Malawi, South Africa and Zambia: Mathematical Modelling Study

Author

Listed:
  • Janne Estill
  • Matthias Egger
  • Leigh F Johnson
  • Thomas Gsponer
  • Gilles Wandeler
  • Mary-Ann Davies
  • Andrew Boulle
  • Robin Wood
  • Daniela Garone
  • Jeffrey S A Stringer
  • Timothy B Hallett
  • Olivia Keiser
  • for the IeDEA Southern Africa Collaboration

Abstract

Objectives: Mortality in patients starting antiretroviral therapy (ART) is higher in Malawi and Zambia than in South Africa. We examined whether different monitoring of ART (viral load [VL] in South Africa and CD4 count in Malawi and Zambia) could explain this mortality difference. Design:: Mathematical modelling study based on data from ART programmes. Methods: We used a stochastic simulation model to study the effect of VL monitoring on mortality over 5 years. In baseline scenario A all parameters were identical between strategies except for more timely and complete detection of treatment failure with VL monitoring. Additional scenarios introduced delays in switching to second-line ART (scenario B) or higher virologic failure rates (due to worse adherence) when monitoring was based on CD4 counts only (scenario C). Results are presented as relative risks (RR) with 95% prediction intervals and percent of observed mortality difference explained. Results: RRs comparing VL with CD4 cell count monitoring were 0.94 (0.74–1.03) in scenario A, 0.94 (0.77–1.02) with delayed switching (scenario B) and 0.80 (0.44–1.07) when assuming a 3-times higher rate of failure (scenario C). The observed mortality at 3 years was 10.9% in Malawi and Zambia and 8.6% in South Africa (absolute difference 2.3%). The percentage of the mortality difference explained by VL monitoring ranged from 4% (scenario A) to 32% (scenarios B and C combined, assuming a 3-times higher failure rate). Eleven percent was explained by non-HIV related mortality. Conclusions: VL monitoring reduces mortality moderately when assuming improved adherence and decreased failure rates.

Suggested Citation

  • Janne Estill & Matthias Egger & Leigh F Johnson & Thomas Gsponer & Gilles Wandeler & Mary-Ann Davies & Andrew Boulle & Robin Wood & Daniela Garone & Jeffrey S A Stringer & Timothy B Hallett & Olivia K, 2013. "Monitoring of Antiretroviral Therapy and Mortality in HIV Programmes in Malawi, South Africa and Zambia: Mathematical Modelling Study," PLOS ONE, Public Library of Science, vol. 8(2), pages 1-8, February.
  • Handle: RePEc:plo:pone00:0057611
    DOI: 10.1371/journal.pone.0057611
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    References listed on IDEAS

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    1. Martin W G Brinkhof & Mar Pujades-Rodriguez & Matthias Egger, 2009. "Mortality of Patients Lost to Follow-Up in Antiretroviral Treatment Programmes in Resource-Limited Settings: Systematic Review and Meta-Analysis," PLOS ONE, Public Library of Science, vol. 4(6), pages 1-9, June.
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    1. Andrew Phillips & Valentina Cambiano & Fumiyo Nakagawa & Travor Magubu & Alec Miners & Debbie Ford & Deenan Pillay & Andrea De Luca & Jens Lundgren & Paul Revill, 2014. "Cost-Effectiveness of HIV Drug Resistance Testing to Inform Switching to Second Line Antiretroviral Therapy in Low Income Settings," PLOS ONE, Public Library of Science, vol. 9(10), pages 1-10, October.

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