Browsing by Author "Bock, Peter"

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    Availability of antiretroviral therapy is associated with increased uptake of HIV testing services
    (2005) Mfundisi, Coceka; Chiranjan, Nirasha; Rodrigues, Charl; Kirchner, Launel; Bock, Peter; Myer, Landon
    Voluntary counselling and testing (VCT) is an important tool in HIV prevention efforts and in the identification of HIV-infected individuals for care and treatment services. But despite the central role of VCT in the response to HIV/AIDS, less than 20% of South Africans have been tested for HIV. Although there are substantial barriers to seeking VCT, including quality of services and AIDS-related stigma, improving VCT rates remains a critical part of the response to the HIV/AIDS epidemic. Recently there has been particular interest in the potential influence of access to antiretroviral therapy (ART) on demand for HIV testing services. It has been suggested that the availability of effective treatment for HIV/AIDS may help motivate individuals to find out their HIV status. However, this possibility remains largely hypothetical and there have been few studies investigating this question. In light of the importance of VCT as an entry point to HIV prevention interventions and treatment services, the possible impact of ART availability on VCT uptake has major implications for the public health response to HIV/AIDS in South Africa. We investigated whether the availability of ART was associated with HIV testing among individuals attending the site B day hospital in Khayelitsha near Cape Town, the setting for a well-publicised antiretroviral pilot.
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    Better antiretroviral therapy outcomes at primary healthcare facilities: an evaluation of three tiers of ART services in four South African provinces
    (Public Library of Science, 2010) Fatti, Geoffrey; Grimwood, Ashraf; Bock, Peter
    BACKGROUND: There are conflicting reports of antiretroviral therapy (ART) effectiveness comparisons between primary healthcare (PHC) facilities and hospitals in low-income settings. This comparison has not been evaluated on a broad scale in South Africa. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective cohort study was conducted including ART-naïve adults from 59 facilities in four provinces in South Africa, enrolled between 2004 and 2007. Kaplan-Meier estimates, competing-risks Cox regression, generalised estimating equation population-averaged models and logistic regression were used to compare death, loss to follow-up (LTFU) and virological suppression (VS) between PHC, district and regional hospitals. 29 203 adults from 47 PHC facilities, nine district hospitals and three regional hospitals were included. Patients at PHC facilities had more advanced WHO stage disease when starting ART. Retention in care was 80.1% (95% CI: 79.3%-80.8%), 71.5% (95% CI: 69.1%-73.8%) and 68.7% (95% CI: 67.0%-69.7%) at PHC, district and regional hospitals respectively, after 24 months of treatment ( P <0.0001). In adjusted regression analyses, LTFU was independently increased at regional hospitals (aHR 2.19; 95% CI: 1.94−2.47) and mortality was independently elevated at district hospitals (aHR 1.60; 95% CI: 1.30−1.99) compared to PHC facilities after 12 months of ART. District and regional hospital patients had independently reduced probabilities of VS, aOR 0.76 (95% CI: 0.59−0.97) and 0.64 (95% CI: 0.56−0.75) respectively compared to PHC facilities over 24 months of treatment. Conclusions/Significance: ART outcomes were superior at PHC facilities, despite PHC patients having more advanced clinical stage disease when starting ART, suggesting that ART can be adequately provided at this level and supporting the South African government's call for rapid up-scaling of ART at the primary level of care. Further prospective research is required to determine the degree to which outcome differences are attributable to either facility level characteristics or patient co-morbidity at hospital level.
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    Increased vulnerability of rural children on antiretroviral therapy attending public health facilities in South Africa: a retrospective cohort study
    (BioMed Central Ltd., 2010) Fatti, Geoffrey; Bock, Peter; Grimwood, Ashraf; Eley, Brian
    BACKGROUND: A large proportion of the 340,000 HIV-positive children in South Africa live in rural areas, yet there is little sub-Saharan data comparing rural paediatric antiretroviral therapy (ART) programme outcomes with urban facilities. We compared clinical, immunological and virological outcomes between children at seven rural and 37 urban facilities across four provinces in South Africa. METHODS: We conducted a retrospective cohort study of routine data of children enrolled on ART between November 2003 and March 2008 in three settings, namely: urban residence and facility attendance (urban group); rural residence and facility attendance (rural group); and rural residents attending urban facilities (rural/urban group). Outcome measures were: death, loss to follow up (LTFU), virological suppression, and changes in CD4 percentage and weight-for-age-z (WAZ) scores. Kaplan-Meier estimates, logrank tests, multivariable Cox regression and generalized estimating equation models were used to compare outcomes between groups. RESULTS: In total, 2332 ART-naive children were included, (1727, 228 and 377 children in the urban, rural and rural/urban groups, respectively). At presentation, rural group children were older (6.7 vs. 5.6 and 5.8 years), had lower CD4 cell percentages (10.0% vs. 12.8% and 12.7%), lower WAZ scores (-2.06 vs. -1.46 and -1.41) and higher proportions with severe underweight (26% vs.15% and 15%) compared with the urban and rural/urban groups, respectively. Mortality was significantly higher in the rural group and LTFU significantly increased in the rural/urban group. After 24 months of ART, mortality probabilities were 3.4% (CI: 2.4-4.8%), 7.7% (CI: 4.5-13.0%) and 3.1% (CI: 1.7-5.6%) p = 0.0137; LTFU probabilities were 11.5% (CI: 9.3-14.0%), 8.8% (CI: 4.5-16.9%) and 16.6% (CI: 12.4-22.6%), p = 0.0028 in the urban, rural and rural/urban groups, respectively. The rural group had an increased adjusted mortality probability, adjusted hazards ratio 2.41 (CI: 1.25-4.67) and the rural/urban group had an increased adjusted LTFU probability, aHR 2.85 (CI: 1.41-5.79). The rural/urban group had a decreased adjusted probability of virological suppression compared with the urban group at any timepoint on treatment, adjusted odds ratio 0.67 (CI: 0.48-0.93). CONCLUSIONS: Rural HIV-positive children are a vulnerable group, exhibiting delayed access to ART and an increased risk of poor outcomes while on ART. Expansion of rural paediatric ART programmes, with future research exploring improvements to rural health system effectiveness, is required.
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    A review of the routine monitoring data for antiretroviral patients in the public health sector in the Western Cape Province, South Africa
    (2008) Bock, Peter; Boulle, Andrew; London, Leslie
    [Introduction] The first patients started on antiretroviral therapy (ART) in the Western Cape Province public health service began treatment as early as January 2001. These patients were funded jointly by non-government sources, such as the Desmond Tutu Foundation (DTF) and Medecins Sans Frontieres (MSF), and the state, on account of the then limited availability of government funding for ART. The government funded rollout of ART in South Africa began in April 2004. Concerns about poor adherence and viral resistance led to a nationwide emphasis on the development of a good monitoring system for ART. The Provincial Government of the Western Cape (PGWC) has, in conjunction with the World Health Organization (WHO). developed a monitoring system to provide quarterly outcome data for patients on ART. [Aims and Objectives] This study aims to describe and describe and analyse routine data produced on defined clinical and immunological outcomes of patients on ART by the monitoring system, thus assessing the feasibility of an ART programme in the public health sector in the Western Cape Province. [Methods] This study reviewed patient information captured in both the paper based monitoring system and electronic databases. Data on all patients started on ART since January 2001 until June 2005 was included in the study. The monitoring system, developed by the WHO, uses paper-based ART registers at clinics to capture relevant patient information. All patients less than 15 years of age were classified as chitdren. The baseline data recorded in the monitoring system is limited to the percentage of children with a baseline CD4 percentage < 15% and the percentage of children who were treatment-experienced.