treatment (ART) programme has achieved good results, analysis of nine years of
data published in The Lancet Global Health
shows. The overall mortality rate was 8%. Mortality rates were highest during
the first year after starting ART and fell dramatically during subsequent years
The research was
undertaken by an international team of investigators, who argue that Botswana’s
ART programme “successfully reduced mortality among patients with AIDS to
levels much the same as those reported in other low-income or middle-income
countries, and continued to improve this low mortality rate over the study
period”. Other recent research showed the “astounding”
success of South Africa’s ART programme.
In 2002, Botswana
became the first country in sub-Saharan Africa to introduce a national ART
programme. Called Masa, the programme provides free and universal therapy according
to national guidelines. The CD4 count threshold for starting ART was initially
200 cells/mm3. This was increased to 250 cells/mm3 in
2008 and further increased to 350 cells/mm3 in 2013. By November
2012, over 200,000 people were receiving ART thanks to Masa.
the electronic records of patients who started ART between 2002 and 2010 to
assess mortality rates, loss to follow-up, and CD4 count trends.
population comprised 126,263 adult patients. Approximately two-thirds (63%)
were women and the median baseline CD4 cell count was 151 cells/mm3.
However, 13% of patients had a CD4 count below 50 cells/mm3 when
they started therapy and 36% had a count between 50 and 150 cells/mm3.
CD4 count increased in each year of analysis from 101 cells/mm3 in
2002 to 191 cells/mm3 in 2010. Overall, patients’ CD4 counts
increased significantly during the first 24 weeks of ART, and a count of 350
cells/mm3 was achieved an average of 24 months after treatment
A total of 10,230
(8%) deaths were documented during the nine years of the study. The overall
mortality rate was 2.71 deaths per 100 person-years. Mortality was highest
during the first three months of treatment (12.8 deaths per 100 person-years)
but fell to 3.46 deaths per 100 person-years by month six of therapy. The
mortality rate in the second year of ART was 1.16 death per 100 person-years.
Mortality then steadily declined over the next seven years of follow-up to 0.17
deaths per 100 person-years.
In 2002, the first
year of the programme, 29% of patients who enrolled died. But in 2009, only 3%
of those entering the programme died. The proportion of the total enrolled population
dying per year fell from 63% in 2002 to 0.8% in 2009.
A total of 15,270
patients were lost to follow-up, with approximately a fifth of patients
dropping out of care in the first year of therapy. “Loss to follow-up, or lack
of electronic documentation, seems to be an important issue to be addressed,”
comment the investigators.
They assumed that
60% of lost-to-follow-up patients had died, increasing the overall mortality
rate from 8% to between 11 and 13%.
Despite this, the
authors believe that Botswana’s ART programme has been a success, and conclude that,
“as treatment improves and patients live longer, the national ART programme
will need to deal with ART-related toxicities and non-AIDS defining disorders."
The author of an
accompanying editorial praised the study as “a welcome addition to the
scientific literature on ART programmes”.