One-quarter died on HIV treatment waiting list in South Africa's Free State province

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Almost a quarter of patients eligible for HIV treatment in South Africa’s Free State province died before getting it, a further 13% disappeared from the healthcare system and 5% were still on a waiting list, according to a review of three years of progress in the province’s public sector antiretroviral treatment (ART) programme.

The findings were reported on Thursday at the Seventeenth Conference on Retroviruses and Opportunistic Infections (CROI) in San Francisco.

As scale-up progresses important measures of a programme’s success include how many of those who meet the criteria to start treatment do in fact start, as well what proportion die before beginning treatment.


inter-quartile range

The spread of values, from the smallest to the largest. The inter-quartile range (IQR) only includes the middle 50% of values and measures the degree of spread of the most common values.


Expresses the risk that, during one very short moment in time, a person will experience an event, given that they have not already done so.

hazard ratio

Comparing one group with another, expresses differences in the risk of something happening. A hazard ratio above 1 means the risk is higher in the group of interest; a hazard ratio below 1 means the risk is lower. Similar to ‘relative risk’.

opportunistic infection (OI)

An infection that occurs more frequently or is more severe in people with weakened immune systems, such as people with low CD4 counts, than in people with healthy immune systems. Opportunistic infections common in people with advanced HIV disease include Pneumocystis jiroveci pneumonia; Kaposi sarcoma; cryptosporidiosis; histoplasmosis; other parasitic, viral, and fungal infections; and some types of cancer. 


A doctor, nurse or other healthcare professional who is active in looking after patients.

Until recently the primary focus has been on the outcomes of patients who start treatment. However, the highest rates of mortality happen within the first month on treatment, raising the question: what happens to the people who are caught in the system, waiting to start on treatment?

At last year’s International AIDS Society conference in Cape Town, South African HIV Clinician’s Society president Dr Francois Venter warned that South Africa’s health system was doing bad job of getting people on to treatment early enough and quickly enough.

This analysis looked at how well one province in South Africa is doing in ensuring that patients with HIV receive prompt treatment once they become eligible for it.

Free State has the third-highest HIV prevalence rate among the nine provinces of South Africa.

From May 2004 until December 2007 all ART eligible patients (with a CD4 cell count under 200 cells/mm³) enrolled at the clinics in the Free State treatment programme were followed until December 2008. Time was measured from the (first) baseline CD4 count until whichever event came first: the start of antiretroviral therapy or death.

Data are collected routinely from enrolment and are linked to the national death register and National Health Laboratory Service (NHLS) database.

Of the 59% (12,963) who started antiretroviral therapy, men had a higher risk of death (hazard ratio [HR] 1.29 95% confidence interval [CI]: 1.22-1.36) and were less likely to start treatment compared to women (HR 0.83 95% CI: 0.80-0.86).

The lower the CD4 cell count at eligibility the higher the proportion of those likely to die before starting ART and the greater the probability of not starting treatment. Of the 15% (3207) with a CD4 cell count under 25 cells/mm3 at eligibility, close to 50% died before starting treatment.

Survival improved over time. Of those who enrolled in 2007 56% more had started treatment compared to those who enrolled during 2004 or 2005 and were less likely to die (HR 0.64 95% CI: 0.59-0.68).

Among 2991 patients with a median CD4 cell count of 260 (interquartile range [IQR] 227-318), and so not yet eligible for treatment, the median time to their next CD4 cell count measurement was, in accordance with national guidelines, six months (183 days, IQR 105-309). Subsequently their median CD4 count for eligibility was 101 (IQR 47-154) with a median decrease between CD4 count measures of 113 (IQR 70-183).

These findings provide further evidence for reducing pre-ART mortality and improving survival by getting those who are most severely immune-compromised on to treatment as soon as possible, as well as improving access for men.

National treatment guidelines have recently changed to recommend earlier treatment at a CD4 count below 350 cells/mm3, so those starting treatment will do so at a higher CD4 count. However, as the Free State study shows, patients with higher CD4 cell counts are being monitored too infrequently for the timely start of treatment, undermining the value for the health system and the individual of recommending earlier treatment.

Further information

You can view the abstract on the official conference website.

You can also view a webcast and slides of this session on the official conference website.


Ingle S et al. Pre-treatment mortality and probability of starting ART in patients enrolled in the Free State ARV program, South Africa: implications for treatment guidelines. Seventeenth Conference on Retroviruses and Opportunistic Infections, San Francisco, abstract 108, February 2010.