Background Potential causes of poor antiretroviral therapy (ART) treatment outcomes can be patient or health system related. Data on the effect of health system on ART outcomes is scarce.
Objective: To compare treatment outcomes of HIV positive adults (≥18 years) initiating ART in either private or public HIV clinics in Johannesburg, South Africa.
Methods: A retrospective cohort analysis was conducted on HIV positive, ART naïve adults initiating ART at a public (Themba Lethu Clinic) or private HIV clinic in Johannesburg between 01 January 2005 and 31 December 2011. Treatment outcomes included mortality, loss to follow up (LTFU; defined as >90 days since last scheduled visit date), failure to suppress viral load (>400copies/ml) at 6 and 12 months and absolute change in CD4 count from baseline until 6 and or 12 months after ART initiation. Survival analysis was performed using Kaplan Meir curves. Multivariate Cox proportional hazards models were used to assess predictors of mortality and LTFU. Generalized estimation equations were used to determine predictors of failure to suppress viral load while absolute change in CD4 count was analysed using the Wilcoxon rank sum test.
Results: A total of 11690 patients initiated ART at the public clinic compared to 574 at the private clinic. Patients were similar in terms of age, gender and baseline viral load. Private clinic patients were less likely to die [aHR=0.39;95% CI 0.14-1.06] or to be retained on ART [aHR=1.59;95% CI 0.94-2.70], although both estimates lacked statistical significance. Public clinic patients presented with advanced HIV [WHO stage 3 or 4, p<0.001] compared to the private clinic. However, private clinic patients were 63% more likely to have a detectable viral load at 12 months of follow up [RR=1.63;95% CI 1.15-2.32]. There were no differences in the absolute CD4 changes between the private and public clinic at 6 months (median 99 IQR 43-78 vs. 103 IQR 52- 168; p=0.584) respectively.
Conclusion: This study demonstrates that health systems have an influence on ART outcomes. The private sector is commended for early initiation of treatment and the availability of a variety of ARV drugs. However there is need for standardization of prescribing practices and care. Better virological responses amongst public patients can be attributed to better adherence to treatment and reduced LTFU rates compared to the private sector. Public-private partnerships are thus encouraged to address shortcomings of either sector.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/14602 |
| Date | 25 April 2014 |
| Creators | Moyo, Faith |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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