Mortality and retention in hospital-based and CDC-based antiretroviral service delivery in people living with HIV in the Guangdong Province, China: a prospective cohort study.

BACKGROUND: Enormous efforts have been made to decentralise HIV service delivery in China, gradually developing a network of thousands of Centres For Disease Control And Prevention (CDCs) with or without local hospitals providing antiretroviral therapy (ART) to every village or equivalent. However, in the Guangdong Province, China, most infected patients from CDCs delivering HIV services have been switched to sentinel hospitals, providing an opportunity to examine this shift on linkage to care, retention, and mortality among people living with HIV. We examined long-term outcomes of people living with HIV who accessed services through sentinel hospitals and CDCs in the Guangdong Province.

METHODS: This is a post-hoc analyses of an open cohort from an observational database of 22 qualified HIV/AIDS sentinel hospitals and two CDC-based drug delivery health facilities in Guangdong. We recruited all outpatients of health facilities receiving ART from Jan 1, 2005, to June 1, 2014. Patients were excluded if they did not start triple drug therapy based ART, had missing treatment regimen information, or used ART outside of national guidelines. We followed up the patients for 10 years. We defined and calculated linkage to initial ART, mortality, overall survival, and retention rate according to the WHO Guideline 2006 for ART in HIV infection in adult. The institutional review board of the Guangzhou Eighth People's Hospital approved this analysis. Written informed consent was obtained from all patients.

FINDINGS: Of the 18 921 people living with HIV, 14 885 (79%) were initiated ART with follow-up, and thus were available for analysis. Among these participants, 12 966 (87%) individuals received ART from hospitals and 1919 (13%) received ART from a CDC, the linkage to care was 80·7% in hospitals and 79·9% in CDC facilities (p=0·352). Excess mortality was 1·4 deaths per 100 person-years (95% CI 1·1-1·8) in CDC facilities compared with 0·4 deaths per 100 person-years (0·3-0·5) in hospitals (p=0·001). A Cox-regression analysis showed that mortality was much higher in patients receiving ART from the CDC-based health facilities than in those receiving ART from the sentinel hospitals, with an adjusted hazard ratio (HR) of 3·3 (95% CI 2·3-4·6). Kaplan-Meier analysis showed a mean overall survival time of 105·3 months (95% CI 104·6-106·1) in the hospital group compared with 78·7 months (76·2-81·2) in the CDC group (p<0·0001). Retention rate was 94·1% in sentinel hospital and 84·0% in CDC facilities (p<0·0001). A crude HR of treatment termination in CDC health facilities was 7·5 (95% CI 6·3-9·0) compared with hospital geographical distributions.

INTERPRETATION: Sentinel hospital HIV service delivery had better retention, and substantially lower mortality than did CDC-based service delivery. This study has implications for the expansion HIV service delivery, and should be made to adopt a sentinel hospital-based system of integrated HIV care and treatment.

FUNDING: This study was supported by Twelve Fifth Key Research grant from the Ministry of Science and Technology, People's Republic of China (2012ZX10001003-003), Science and Technology Program of Guangzhou (201300000092), and the US National Institutes of Health Fogarty International Center Global Infectious Diseases Training Grant (1D43TW009532-01). These fundings had no role in study design and data analyses.