Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa

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dc.contributor.authorBrinkhof, Martin W Gen_ZA
dc.contributor.authorSpycher, Ben Den_ZA
dc.contributor.authorYiannoutsos, Constantinen_ZA
dc.contributor.authorWeigel, Ralfen_ZA
dc.contributor.authorWood, Robinen_ZA
dc.contributor.authorMessou, Eugèneen_ZA
dc.contributor.authorBoulle, Andrewen_ZA
dc.contributor.authorEgger, Matthiasen_ZA
dc.contributor.authorSterne, Jonathan A Cen_ZA
dc.contributor.author(IeDEA), for the International epidemiological Database to Evaluate AIDSen_ZA
dc.date.accessioned2015-11-23T12:25:38Z
dc.date.available2015-11-23T12:25:38Z
dc.date.issued2010en_ZA
dc.description.abstractBACKGROUND: Evaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-level mortality in the first year of antiretroviral treatment (ART) for excess mortality in patients lost to follow-up. Methods and FINDINGS: Treatment-naïve patients starting combination ART in five programmes in Côte d'Ivoire, Kenya, Malawi and South Africa were eligible. Patients whose last visit was at least nine months before the closure of the database were considered lost to follow-up. We filled missing survival times in these patients by multiple imputation, using estimates of mortality from studies that traced patients lost to follow-up. Data were analyzed using Weibull models, adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment programme. A total of 15,915 HIV-infected patients (median CD4 cell count 110 cells/µL, median age 35 years, 68% female) were included; 1,001 (6.3%) were known to have died and 1,285 (14.3%) were lost to follow-up in the first year of ART. Crude estimates of mortality at one year ranged from 5.7% (95% CI 4.9-6.5%) to 10.9% (9.6-12.4%) across the five programmes. Estimated mortality hazard ratios comparing patients lost to follow-up with those remaining in care ranged from 6 to 23. Adjusted estimates based on these hazard ratios ranged from 10.2% (8.9-11.6%) to 16.9% (15.0-19.1%), with relative increases in mortality ranging from 27% to 73% across programmes. CONCLUSIONS: Naïve survival analysis ignoring excess mortality in patients lost to follow-up may greatly underestimate overall mortality, and bias ART programme evaluations. Adjusted mortality estimates can be obtained based on excess mortality rates in patients lost to follow-up.en_ZA
dc.identifier.apacitationBrinkhof, M. W. G., Spycher, B. D., Yiannoutsos, C., Weigel, R., Wood, R., Messou, E., ... (2010). Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa. <i>PLoS One</i>, http://hdl.handle.net/11427/15274en_ZA
dc.identifier.chicagocitationBrinkhof, Martin W G, Ben D Spycher, Constantin Yiannoutsos, Ralf Weigel, Robin Wood, Eugène Messou, Andrew Boulle, Matthias Egger, Jonathan A C Sterne, and "Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa." <i>PLoS One</i> (2010) http://hdl.handle.net/11427/15274en_ZA
dc.identifier.citationBrinkhof, M. W., Spycher, B. D., Yiannoutsos, C., Weigel, R., Wood, R., Messou, E., ... & Sterne, J. A. (2010). Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa. PloS one, 5(11), e14149. doi:10.1371/journal.pone.0014149en_ZA
dc.identifier.ris TY - Journal Article AU - Brinkhof, Martin W G AU - Spycher, Ben D AU - Yiannoutsos, Constantin AU - Weigel, Ralf AU - Wood, Robin AU - Messou, Eugène AU - Boulle, Andrew AU - Egger, Matthias AU - Sterne, Jonathan A C AU - (IeDEA), for the International epidemiological Database to Evaluate AIDS AB - BACKGROUND: Evaluation of antiretroviral treatment (ART) programmes in sub-Saharan Africa is difficult because many patients are lost to follow-up. Outcomes in these patients are generally unknown but studies tracing patients have shown mortality to be high. We adjusted programme-level mortality in the first year of antiretroviral treatment (ART) for excess mortality in patients lost to follow-up. Methods and FINDINGS: Treatment-naïve patients starting combination ART in five programmes in Côte d'Ivoire, Kenya, Malawi and South Africa were eligible. Patients whose last visit was at least nine months before the closure of the database were considered lost to follow-up. We filled missing survival times in these patients by multiple imputation, using estimates of mortality from studies that traced patients lost to follow-up. Data were analyzed using Weibull models, adjusting for age, sex, ART regimen, CD4 cell count, clinical stage and treatment programme. A total of 15,915 HIV-infected patients (median CD4 cell count 110 cells/µL, median age 35 years, 68% female) were included; 1,001 (6.3%) were known to have died and 1,285 (14.3%) were lost to follow-up in the first year of ART. Crude estimates of mortality at one year ranged from 5.7% (95% CI 4.9-6.5%) to 10.9% (9.6-12.4%) across the five programmes. Estimated mortality hazard ratios comparing patients lost to follow-up with those remaining in care ranged from 6 to 23. Adjusted estimates based on these hazard ratios ranged from 10.2% (8.9-11.6%) to 16.9% (15.0-19.1%), with relative increases in mortality ranging from 27% to 73% across programmes. CONCLUSIONS: Naïve survival analysis ignoring excess mortality in patients lost to follow-up may greatly underestimate overall mortality, and bias ART programme evaluations. Adjusted mortality estimates can be obtained based on excess mortality rates in patients lost to follow-up. DA - 2010 DB - OpenUCT DO - 10.1371/journal.pone.0014149 DP - University of Cape Town J1 - PLoS One LK - https://open.uct.ac.za PB - University of Cape Town PY - 2010 T1 - Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa TI - Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa UR - http://hdl.handle.net/11427/15274 ER - en_ZA
dc.identifier.urihttp://hdl.handle.net/11427/15274
dc.identifier.urihttp://dx.doi.org/10.1371/journal.pone.0014149
dc.identifier.vancouvercitationBrinkhof MWG, Spycher BD, Yiannoutsos C, Weigel R, Wood R, Messou E, et al. Adjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africa. PLoS One. 2010; http://hdl.handle.net/11427/15274.en_ZA
dc.language.isoengen_ZA
dc.publisherPublic Library of Scienceen_ZA
dc.publisher.departmentDesmond Tutu HIV Centreen_ZA
dc.publisher.facultyFaculty of Health Sciencesen_ZA
dc.publisher.institutionUniversity of Cape Town
dc.rightsThis is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.en_ZA
dc.rights.holder© 2010 Brinkhof et alen_ZA
dc.rights.urihttp://creativecommons.org/licenses/by/4.0en_ZA
dc.sourcePLoS Oneen_ZA
dc.source.urihttp://journals.plos.org/plosoneen_ZA
dc.subject.otherDeath ratesen_ZA
dc.subject.otherAntiretroviral therapyen_ZA
dc.subject.otherHIV preventionen_ZA
dc.subject.otherAIDSen_ZA
dc.subject.otherAntiretroviralsen_ZA
dc.subject.otherSurvival analysisen_ZA
dc.subject.otherAfricaen_ZA
dc.subject.otherHIV epidemiologyen_ZA
dc.titleAdjusting mortality for loss to follow-up: analysis of five ART programmes in sub-Saharan Africaen_ZA
dc.typeJournal Articleen_ZA
uct.type.filetypeText
uct.type.filetypeImage
uct.type.publicationResearchen_ZA
uct.type.resourceArticleen_ZA
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