Page 278 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 4 of 10 Original Research

Mean Median a Mean Median b
Jhb: Baseline CD4 count by ART start year Mopani: Baseline CD4 count by ART start year
400 400
350 350
Baseline CD4 count 250 Baseline CD4 count 250
300
300
200
200
150
150
100
100
50
0 50 0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
ART start year ART start year
% < 200 % < 100 c % < 200 % < 100 d
Jhb: Percentage baseline CD4 counts < 200 and < 100 cells/mm 3 Mopani: Percentage baseline CD4 counts < 200 and < 100 cells/mm 3
100 100
90 90
80 80
70 70
Percentage 50 Percentage 50
60
60
40
40
30
20
20 30
10 10
0 0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
ART start year ART start year
ART, antiretroviral therapy; Jhb, Johannesburg district.
FIGURE 2: Mean and median baseline CD4 count over time and percentage baseline CD4 counts < 200 and < 100 cells/mm in Johannesburg district (a and c) and Mopani
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district (b and d).
trend, with a consistent increase only being evident from (Figure 3c and d). When ART initiation years were grouped
2009. Although the proportion of baseline CD4 counts according to timing of drug changes in the South African
3
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< 200 cells/mm has decreased over time, particularly from guidelines, clients with baseline CD4 < 200 cells/mm who
2009, there has been no decrease in the last 2 years, with initiated treatment in years when stavudine was in use had
percentage counts < 200 cells/mm remaining at ± 40% in the highest mortality in both districts, with 5-year losses of
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Johannesburg and ± 35% in Mopani (Figure 2c and d). 13% in Johannesburg and 48% in Mopani (Figure 3e and f).
In both districts, clients who initiated treatment after
Mortality survival analysis tenofovir was introduced had lower mortality rates (5-year
losses of 8% and 25%, respectively) and deaths were even
Mortality was significantly higher among clients who lower after the introduction of an FDC (5-year losses of 4%
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initiated ART with CD4 counts < 200 cells/mm compared and 17%, respectively).
to those with higher baseline CD4 counts, with 5-year
death rates of 6%, 2% and 1% among clients with CD4 Characteristics and outcomes of clients initiating
counts < 200, 200–349 and ≥ 350 cells/mm , respectively, in antiretroviral therapy at CD4 < 200 cells/mm 3
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Johannesburg and 23%, 7% and 5%, respectively, for the
same CD4 counts in Mopani (p < 0.001 for both districts) Compared to clients with baseline CD4 counts ≥ 200
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(Figure 3a and b). Early deaths immediately after ART cells/mm , clients who initiated ART in 2017 with low
initiation among clients with baseline CD4 < 200 cells/mm baseline CD4 counts were more likely to be men and to
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are clearly evident. Even in recent years (2016 and 2017), initiate treatment at older ages (p < 0.001) (Table 2). Clients
clients with baseline CD4 < 200 cells/mm had significantly with low baseline CD4 in both districts were more likely
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higher mortality than those with higher CD4 counts (losses to initiate ART at a hospital compared to those starting
of 2.4% and 0.4% in Johannesburg and 9% and 2% in Mopani ART with higher CD4 counts (p < 0.001). This correlates
among clients with CD4 counts < 200 and ≥ 200 cells/mm , with findings of more advanced clinical stage in clients
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respectively (p < 0.001 for both districts)). Among clients with low baseline CD4 (p < 0.001). Among women aged
with baseline CD4 < 200 cells/mm , mortality was lower 15–50 years, a significantly lower percentage of clients
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among those who initiated ART in recent years compared to with CD4 < 200 were pregnant during ART initiation
those who initiated treatment in earlier years of the ART compared to women with higher baseline counts in both
programme (p < 0.001 for both Johannesburg and Mopani) districts (p < 0.001).

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