Early mortality among adults accessing antiretroviral treatment programmes in sub-Saharan Africa

aDesmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa bClinical Research Unit, Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK cHIV Unit, Ministry of Health, Malawi dFamily Health International, Malawi Country Office, Lilongwe, Malawi eProgramme PAC-CI, Abidjan, Ivory Coast, France fINSERM, Unité 897, Centre de Recherche Epidémiologie et Biostatistique, Bordeaux, France gInfectious Diseases Epidemiology Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa hDepartment of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA.
AIDS (London, England) (Impact Factor: 6.56). 11/2008; 22(15):1897-908. DOI: 10.1097/QAD.0b013e32830007cd
Source: PubMed

ABSTRACT Two-thirds of the world's HIV-infected people live in sub-Saharan Africa, and more than 1.5 million of them die annually. As access to antiretroviral treatment has expanded within the region; early pessimism concerning the delivery of antiretroviral treatment using a large-scale public health approach has, at least in the short term, proved to be broadly unfounded. Immunological and virological responses to ART are similar to responses in patients treated in high-income countries. Despite this, however, early mortality rates in sub-Saharan Africa are very high; between 8 and 26% of patients die in the first year of antiretroviral treatment, with most deaths occurring in the first few months. Patients typically access antiretroviral treatment with advanced symptomatic disease, and mortality is strongly associated with baseline CD4 cell count less than 50 cells/mul and WHO stage 4 disease (AIDS). Although data are limited, leading causes of death appear to be tuberculosis, acute sepsis, cryptococcal meningitis, malignancy and wasting syndrome. Mortality rates are likely to depend not only on the care delivered by antiretroviral treatment programmes, but more fundamentally on how advanced disease is at programme enrollment and the quality of preceding healthcare. In addition to improving delivery of antiretroviral treatment and providing it free of charge to the patient, strategies to reduce mortality must include earlier diagnosis of HIV infection, strengthening of longitudinal HIV care and timely initiation of antiretroviral treatment. Health systems delays in antiretroviral treatment initiation must be minimized, especially in patients who present with advanced immunodeficiency.

1 Follower
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background The causes of severe morbidity in health facilities implementing Antiretroviral Treatment (ART) programmes are poorly documented in sub-Saharan Africa. We aimed to describe severe morbidity among HIV-infected patients after ART initiation, based on data from an active surveillance system established within a network of specialized care facilities in West African cities. Methods Within the International epidemiological Database to Evaluate AIDS (IeDEA) - West Africa collaboration, we conducted a prospective, multicenter data collection that involved two facilities in Abidjan, Côte d’Ivoire and one in Cotonou, Benin. Among HIV-infected adults receiving ART, events were recorded using a standardized form. A simple case-definition of severe morbidity (death, hospitalization, fever > 38°5C, Karnofsky index < 70%) was used at any patient contact point. Then a physician confirmed and classified the event as WHO stage 3 or 4 according to the WHO clinical classification or as degree 3 or 4 of the ANRS scale. Results From December 2009 to December 2011, 978 adults (71% women, median age 39 years) presented with 1449 severe events. The main diagnoses were: non-AIDS-defining infections (33%), AIDS-defining illnesses (33%), suspected adverse drug reactions (7%), other illnesses (4%) and syndromic diagnoses (16%). The most common specific diagnoses were: malaria (25%), pneumonia (13%) and tuberculosis (8%). The diagnoses were reported as syndromic in one out of five events recorded during this study. Conclusions This study highlights the ongoing importance of conventional infectious diseases among severe morbid events occurring in patients on ART in ambulatory HIV care facilities in West Africa. Meanwhile, additional studies are needed due to the undiagnosed aspect of severe morbidity in substantial proportion. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-0910-3) contains supplementary material, which is available to authorized users.
    BMC Infectious Diseases 04/2015; 15(1). DOI:10.1186/s12879-015-0910-3 · 2.56 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To assess if cotrimoxazole prophylaxis administered early during antiretroviral therapy (ART) reduces mortality in Chinese adults who are infected with human immunodeficiency virus (HIV). We did a retrospective observational cohort study using data from the Chinese national free antiretroviral database. Patients older than 14 years who started ART between 1 January 2010 and 31 December 2012 and had baseline CD4+ T-lymphocyte (CD4+ cell) count less than 200 cells/µL were followed until death, loss to follow-up or 31 December 2013. Hazard ratios (HRs) for several variables were calculated using multivariate analyses. The analysis involved 23 816 HIV-infected patients, 2706 of whom died during the follow-up. Mortality in patients who did and did not start cotrimoxazole during the first 6 months of ART was 5.3 and 7.0 per 100 person-years, respectively. Cotrimoxazole was associated with a 37% reduction in mortality (hazard ratio, HR: 0.63; 95% confidence interval, CI: 0.56-0.70). Cotrimoxazole in addition to ART reduced mortality significantly over follow-up lasting 6 months (HR: 0.65; 95% CI: 0.59-0.73), 12 months (HR: 0.58; 95% CI: 0.49-0.70), 18 months (HR: 0.49; 95% CI: 0.38-0.63) and 24 months (HR: 0.66; 95% CI: 0.48-0.90). The mortality reduction was evident in patients with baseline CD4+ cell counts less than 50 cells/µL (HR: 0.60; 95% CI: 0.54-0.67), 50-99 cells/µL (HR: 0.66; 95% CI: 0.56-0.78) and 100-199 cells/µL (HR: 0.78; 95% CI: 0.62-0.98). Cotrimoxazole prophylaxis started early during ART reduced mortality and should be offered to HIV-infected patients in low- and middle-income countries.
    Bulletin of the World Health Organisation 03/2015; 93(3):152-60. DOI:10.2471/BLT.14.142745 · 5.11 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Abstract Background: In this study, it was hypothesized that tuberculosis co-infection independently increases the risk of mortality in people living with HIV (PLWHs) even if they are on antiretroviral therapy (ART). Therefore, investigating this hypothesis among cohort of adult PLWHs in south west Ethiopia was the aim of the present work. Methods: A cohort study was conducted from December to August 2012 at Jimma University Specialized Hospital (JUSH). PLWHs initiating ART between 2008 and 2011 were included using simple random sampling. The effect of TB co-infection on all-cause mortality was assessed using Cox proportional hazard model. Results: In crude analysis, all-cause mortality of TB co-infected patients was higher by 6.5% (P=0.004). However, multivariate analysis showed that TB co-infection didn’t increase mortality (AHR, 1.31(0.573-3.007), P=0.52). Instead, factors which increased death were low baseline functional status, malnutrition, CD4 count <100cells/mm3 at the initiation of ART. Conclusion: In this study, it was shown that TB co-infection didn’t independently increase mortality provided that patient is on ART. Therefore, beside TB, addressing patient’s nutritional status and intervention to facilitate early presentation to health facilities before they deteriorate functionally and immunologically is mandatory to reduce mortality on ART.
    Journal of AIDS & Clinical Research 09/2014; 5(9):350. DOI:10.4172/2155-6113.1000350 · 6.83 Impact Factor

Full-text (2 Sources)

Available from
Jun 1, 2014