Our results are consistent with two other reports from East Africa: in a large cohort of 23 539 Kenyan patients,

median baseline CD4 counts increased from 119 cells/μL at the start of roll-out in 2003 to 172 cells/μL in later years (2004–2006) [22]. Data from Ethiopia on WHO stage at ART initiation, for which a higher stage in general corresponds to a lower CD4 cell count, showed that 94% of patients initiated ART at WHO stage III or IV before ART roll-out (2003–2006), 83% in the rapid scale-up phase (2006–2007) and 65% in recent years http://www.selleckchem.com/products/ink128.html (2008–2009) [23]. We postulate that improved adherence to national guidelines, better training of medical officers, faster ART initiation and retention of HIV-positive, not yet ART-eligible patients has led to the increased baseline CD4 cell Metformin mw counts in our clinic. We expect the earlier presentation of patients to our clinic, as shown by the higher CD4 cell counts at registration, to also have contributed to this increase. Improved services can be inferred from patients starting ART at higher CD4 cell counts and a larger proportion of eligible patients initiating

ART. However, interruptions in drug supply and/or funding can jeopardize these improved services at short notice, as happened in our clinic in 2006 and 2009, when a relatively low proportion of eligible patients started treatment [24, 25]. Our data show that mortality after ART initiation in our clinic decreased significantly over time. Rates were lower than earlier published results from the IDI [13], but are similar to other rates published for resource-limited settings [11, 26]. A decrease DNA Synthesis inhibitor in mortality over time since ART roll-out was also reported in South Africa [20]. Lower mortality in our clinic was significantly associated

with higher CD4 cell counts at ART initiation, as well as with previously published factors such as female sex and a younger age at ART initiation [11, 12, 27]. Independent of a higher baseline CD4 cell count, a later year of ART initiation was significantly associated with lower mortality. This suggests an additional advantage to starting ART in 2009 compared with 2005, regardless of the increased CD4 cell count in 2009. We attribute this to an overall better standard of care at the IDI as the clinic became more experienced and accustomed to the patient load in the later years after ART roll-out, as evidenced by improved programme performance characteristics. Programmatic improvements included three Continuing Medical Education (CME) sessions a week, an electronic patient information system, a home visiting programme, task shifting for stable patients to nurse-based care and a pharmacy-only refill programme [28], among others.