The impact of gender and income on survival and retention in a South African antiretroviral therapy programme

OBJECTIVES Despite the rapid expansion of antiretroviral therapy ( ART) services in Africa, there are few data on whether outcomes differ for women and men and what factors may drive such variation. We investigated the association of gender and income with survival and retention in a South African ART programme. METHODS A total of 2196 treatment-naive adults were followed for 1 year on ART. Proportional hazards regression was used to explore associations between baseline characteristics and survival and loss-to-follow-up (LTFU). RESULTS Patients were predominantly female (67%). Men presented at an older age and with more advanced HIV disease, and during early ART the crude death rate was higher among men than women (22.8 vs 12.5/100 person-years; P = 0.002). However in multivariate analysis, gender was not significantly associated with survival after adjusting for baseline clinical and immunovirological status (HR = 1.46, 95% CI = 0.96-2.22; P = 0.076). In late ART (4-12 months), there was no gender difference in mortality rates (3.5 vs 3.8/100 person-years; P = 0.817). In multivariate analysis, survival was strongly associated with age (HR = 1.05, 95% CI = 1.02-1.09; P < 0.001), CD4 count > 150 vs < 50 cells/mu l (HR = 0.35, 95% CI = 0.14-0.87; P = 0.023) and any monthly income vs none (HR = 0.47, 95% CI = 0.25-0.88; P = 0.018). Having some monthly income was protective against LTFU at 1 year on ART (adjusted HR = 0.56, 95% CI = 0.39-0.82; P = 0.002). CONCLUSION Men's high early mortality on ART appears due largely to their presentation with more advanced HIV disease. Efforts are needed to enrol men into care earlier in HIV disease and to reduce socio-economic inequalities in ART programme outcomes.